Collective Assessment of NHSScotland Special Health Boards

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1 Collective Assessment of NHSScotland Special Health Boards CONTENTS Page Executive Summary and Key Recommendations 2 1. Introduction 3 Better Health Better Care Role of Special Health Boards Drivers of Change 2. Recommendations 8 Annexes A NHSScotland Special Health Boards 12 o NHS o NHS Education Scotland 19 o NHS Health Scotland 25 o NHS National Waiting Times Centre 32 o NHS Quality Improvement 40 o NHS National Services Scotland 47 o Scottish Ambulance Service 56 o State Hospitals Board for Scotland 63 B NHS Board Allocations 2009/10 71 C HEAT Measures 2009/

2 EXECUTIVE SUMMARY AND KEY RECOMMENDATIONS Purpose The Collective Assessment meets the objective described in Better Health, Better Care of considering the role of Special Health Boards within a more mutual NHS. The assessment includes all Special Health Boards in NHSScotland; NHS Education for Scotland, NHS Health Scotland, NHS Quality Improvement Scotland, NHS 24, Scottish Ambulance Service, State Hospitals Board for Scotland and The National Waiting Times Centre Board. The Common Services Agency is also included in this exercise, and for the purposes of this report is described as NHS National Services Scotland and is fully included in the coverage all relevant narrative and recommendations. 1 The aims of the assessment were to identify opportunities for these Boards to respond to the challenges posed by the drivers of change - demographic change, increasing public expectations, financial resources, new technology and the opportunities provided by public sector reform and the Scottish Government s focus on achieving a defined set of national outcomes. Approach Beginning in 2008, a series of bilateral discussions took place between individual Special Health Boards, Territorial Health Boards and the Scottish Government Health Directorates. The preliminary findings of these discussions fed into the next stage of the review which took place in the summer of The second stage of the assessment was taken forward through collective meetings of all Special Health Board Chief Executives and with the Chairs. The proposed recommendations were then shared with Special Health Board Chairs, before being shared again more widely with Territorial Health Boards and the Scottish Government Health Directorates sponsors. Recommendations The recommendations build on the initial work done in 2008/09, but recognise the new tighter resource and quality improvement context for the assessment and reflect a commitment to share the good practice which was identified in the review as already being developed and implemented across NHSScotland. The report also acknowledges the accelerating efforts of Special Health Boards to align their activities to maximise their effectiveness and efficiency. The recommendations are intentionally minimal in number, but are focussed on identifying the key actions for Special Health Boards, Territorial Health Boards and for Scottish Government which will ensure that the sizeable investment of NHSScotland resources in the national resource created by the Special Health Boards realises optimum benefits in terms of the economies of scale and efficiencies, the potential they offer to reduce duplication, share knowledge and increase consistency and quality. The 3 areas of recommendation are as follows: Improving communication and information sharing Maximising economies of scale and reducing duplication Improving leadership and collaboration The Recommendations section sets out the more specific recommendations under each of these broad headings. 1 In legal terms, NSS is not a Special Health Board. The Common Services Agency (CSA), which is now known as NHS National Services Scotland (NSS) was set up as a distinct legal body, as were Health Boards and Special Health Boards, in the NHS (Scotland) Act

3 SECTION 1 INTRODUCTION Better Health Better Care Better Health Better Care set out the Scottish Government s strategy for health and wellbeing in order to achieve the overarching strategic objective of ensuring a Healthier Scotland, through action to help people to sustain and improve their health, especially in disadvantaged communities, ensuring better, local and faster access to healthcare. It describes the concept of a more mutual NHS, built upon the values of co-operation and collaboration which enables the Scottish public, patients and NHS Scotland staff, to play an increasingly significant role in both the management of the service as a whole and the design and delivery of individual packages of care. In describing the organisational implications of a mutual NHS, Better Health Better Care identified the role of Scotland s Special Health Boards in delivering those services that can be offered more effectively and efficiently on a national basis and allowing local Boards to concentrate resources and attention on front line treatment and care. It then actioned the Scottish Government to work with the Special Boards themselves to assess their current and potential future role, in order to demonstrate the value they add in improving services, improving health, achieving economies of scale and minimising unnecessary duplication of investment and effort. Objectives The objectives of the Collective Assessment of Special Health Boards were agreed as being to: assess current and potential roles and opportunities in light of the drivers of change described in Better Health Better Care and the current / future financial climate identify opportunities and proposals to improve the sponsorship arrangements between Special Boards and Scottish Government describe the customer relationships between Special Boards, geographical Boards and the public and suggest proposals to enhance the quality of such relationships. assess the current range and distribution of products, services and functions both horizontally (across and between Special Health Boards) and vertically (across and between Scottish Government, Special Health Boards and territorial NHS Boards) and develop future proposals in the light of the broad quality agenda described in Better Health Better Care assess the current relationships between Special Health Boards and other stakeholders and develop proposals for broadening and strengthening such relationships At the outset, the following issues were deemed to be outside the scope of the Review: changes to the number of Special Health Boards identified in the First Minister s statement to the Scottish Parliament on More Effective Government (January 2008), consideration of the future development of the improvement and scrutiny functions of NHS Quality Improvement Scotland in light of the wider work announced in the First Minister s statement to be taken forward by Scottish Government, the Scottish Parliament s Corporate Body and local authorities consideration of internal management processes, governance structures and staffing levels / requirements within Special Boards. 3

4 Methodology The Collective Assessment was designed to review the current ways of working of Special Health Boards and make a series of recommendations about their future development. The methodology adopted therefore reflects the requirement for a high level assessment rather than a detailed audit / analysis of specific issues which, if required, would be identified as an action for any subsequent stages of work. Following agreement by the Health Directorate s Management Board, the Collective Assessment was initially led by Colin Cook, Deputy Director, Healthcare Planning and Strategy. This phase involved a series of interviews with Chairs, Chief Executive s and other key representatives of the Special Health Boards, a number of Chief Executives from territorial NHS Boards (as key customers ) and Special Health Board sponsors within the Scottish Government Health Directorates. In addition, a workshop with the Planning Directors from the Special Health Boards was used to test and develop key themes. A report of the conclusions of this initial phase was presented to a meeting of the Board Chief Executives in early Further development of the report was taken forward by Jill Vickerman (who took over as Deputy Director, Healthcare Planning and Strategy in March 2009). This second phase primarily involved discussions with Chief Executives and Chairs of Special Health Boards to describe in more detail the roles and activities of each organisation and to provide greater clarity about current activities and future opportunities for improvement. The Role of Special Health Boards NHS Scotland delivers health services through 14 Territorial Boards, each charged with meeting the needs of their local, geographically defined population. This structure is underpinned by a clear policy presumption against the centralisation of services wherever possible and to improve the overall quality of care offered to Scottish patients. NHS Boards are accountable through their respective Chairs to the Cabinet Secretary for Health and Wellbeing for their performance and strategic direction. The Scottish Government Health Directorates issue guidance to enable NHS Boards to set this direction and monitor performance through its Delivery Directorate, based on a series of approximately 30 HEAT (Health, Efficiency, Access and Treatment) performance targets. The Scottish Government Health Directorates therefore play a dual role, as both a Government department, supporting Ministers in their accountability to the Scottish Parliament and people (their civil service role) and as a Head Office of the NHS in Scotland (their Head Office role). The split between Special and Territorial Boards suggests that Special Boards are, by default, designed to provide services where there is no clear patient benefit from decentralised delivery. Whilst their services could therefore be delivered through Territorial Boards, it makes sense to organise them on a pan Scotland basis because of one or more of the following factors: Economies of scale in that a national offer minimises unnecessary overlap and duplication across NHS Scotland and therefore allows services to be delivered more cost effectively than would be possible under a dispersed model Scarcity of skills / experience in that a national offer enables the health service in Scotland to make best use of scare human resources Consistency of approach in that a national offer supports more equitable service provision throughout Scotland Necessary critical mass in that a national offer provides the volume / level of activity required to maintain skills and provide a cost effective service 4

5 UK Regulation in that NHS Scotland is required to interface with or act on behalf of UK wide regulatory bodies such as the GMC, particularly on issues of reserved legislation External International reputation in that a national offer enables the NHS in Scotland to participate more effectively in international discussions and developments within a particular service area, including the provision of appropriate comparative data Drivers of Change Any future development of the role and ways of working of Special Health Boards needs to be assessed against the changes in the environments within which these Boards are operating. Demographic Change Scotland s ageing population and the related growth in the prevalence and complexity of long term conditions within Scottish society, are driving changes in the pattern of demand for healthcare services. Whilst there remains an inevitable demand for what are sometimes regarded as traditional models of delivery centred on acute hospital settings, these demographic influences focus attention on the ability to provide continuous rather than episodic care and support patients in their own homes and local communities wherever possible. This challenges Scotland s Special Boards to: support NHS Scotland to achieve the appropriate balance between specialised services which require national commissioning and delivery and the policy presumption that services will be delivered as locally as possible in order to meet the particular needs of local communities / patient groups provide a supporting infrastructure which ensures equity of access and service quality within a decentralised delivery model support the development and delivery of care which extends beyond the narrow remit of health services and embraces the voluntary and wider public sector in meeting the holistic needs of patients Demographic change also has significant implications for NHS Scotland s workforce, both in terms of the roles, knowledge and skills that are required to deliver the new models of care effectively and also in meeting the recruitment and retention challenges that flow from an ageing population and a competitive labour market for skilled people. These factors, along with legal, regulatory and policy influences (e.g. European Working Time Directive, Modernising Medical Careers, Agenda for Change etc), provide the context for much of the education, training, development and the quality improvement activities of a number of Special Boards. Service expectations Changing societal / consumer expectations of the level and nature of services are challenging all service organisations, including NHS Boards, to develop more responsive relationships with their users and focus on closing the gap between user needs and the services they offer. This, in turn, demands that service organisations are both responsive and flexible and underpins the drive, described within Better Health Better Care, to develop a more mutual NHS in Scotland with structures that enable the public, patient and staff voice to be heard and acted upon. While organisational solutions might vary depending on strategic purpose and local requirements, mutuality requires organisations that are designed, structured and operated in a way that enables them to listen and respond to the views of both internal (NHS Staff, professional groups, other NHS Boards) and external (public, patients, carers, voluntary groups, community planning partners) stakeholders. In particular, it challenges Special Health Boards to: 5

6 understand and maintain a clear focus on the needs and expectations of their customers improve access to services through key service channels (particularly those represented by NHS 24 and Scottish Ambulance Service) enable professionals and the public to work together in a constructive way in order to influence the design and delivery of service, ensuring a clear focus on the patient experience within quality improvement programmes Financial Context In the 3 years to 2007/08, overall investment in the NHS in Scotland increased by 13.6%. This rate of such growth declined to 5.3% over the following 3 year period (2008/09 to 2010/11). In 2009/10 the forecast is that the Special Health Boards will account for 13.4% of the NHS budget (excluding capital). This compares to 11.4% in 2006/07. Much of this increase is as a result of the transfer of specific responsibilities and their associated budgets. The tighter financial climate, set against the ever increasing costs of incorporating advances in treatment, meeting public expectations and delivering a stretching programme of service improvement, will put even greater focus across NHS Scotland on ensuring best value for the Scottish Government s investment in healthcare. As national bodies capable of realising economies of scale, Special Boards are particularly significant to this agenda, particularly in those activities which are non-patient facing. Technological Change The development and introduction of new technologies in both front line services and back office infrastructure offers the potential to address Scotland s healthcare delivery challenges in new and different ways. Special Boards have played a key role in specifying and delivering national approaches but as programmes to systemise the acquisition and distribution of patient data are delivered, the focus is likely to shift from the development of national infrastructure, with a particular focus on the IT community, to the identification and realisation of added value opportunities flowing from that infrastructure, with a much broader focus on clinical and other professional communities across NHS Scotland. NHSScotland Quality Strategy In February 2010, the Cabinet Secretary for Health and Wellbeing announced the shared commitment to pursue world-leading quality person centred, safe and effective healthcare services for everyone in Scotland through a Quality Strategy that builds on the progress that has been made through Better Health Better Care. The Quality Strategy reflects the challenges and opportunities created for NHSScotland as set out above, demographic change, service expectations and the financial context. Special Health Boards clearly have an important part to play in working with Territorial boards, the Scottish Government and with other public sector and Third sector partners to achieve the ambitions of the quality Strategy. The recommendations in this report will make an important contribution to ensuring that this contribution is optimised. Scotland Performs The Scottish Government has identified its overarching purpose as being to focus Government and public services on creating a more successful country, with opportunities for all of Scotland to flourish, through increasing sustainable economic growth. This is set out within a national performance framework (Figure 1) consisting of five high level strategic objectives (creating a Wealthier and Fairer, Healthier, Greener, Smarter and Safer Scotland), underpinned by a 6

7 series of 15 national outcome indicators which describe what the Government wants to achieve and 45 National Indicators which enable an assessment of progress over time. The National Performance Framework challenges all public bodies to demonstrate their contribution to the Scottish Government s overarching objective and provides a clear, structured approach to the performance assessment for all public sector organisations. It therefore has direct implications for Special Boards in that it challenges them to demonstrate their contribution to achieving national outcomes through the Healthier and other strategic agendas, and sets the context within which the Boards will be expected to work in partnership with other parts of the Scottish Public Sector. Special Boards are well placed to engage in partnership working with other national agencies, as well as supporting effective local engagement by Territorial Boards. Public Sector Reform The Scottish Government has made it clear that effective Government can best be achieved by: simplifying the landscape of public sector organisations in Scotland through simpler structures that support the delivery of national strategic objectives and local priorities transparent and clear public service decision making with streamlined scrutiny and control regimes an overall reduction in the number of arms length bodies at a national level improved collaboration and joint working between public services. Its policy drive is based on ensuring public services which are focussed on: the users of services and the development of ongoing personal relationships rather than anonymous one off transactions outcomes and monitoring real improvements in services delivering value for money through public services that drive up efficiency and ensure best value. Whilst the potential impact of the public sector reform process in terms of the number and structure of Special Health Boards is explicitly outwith the remit of this Collective Assessment, it does represent a key contextual factor in the future proofing of any recommendations. The Public Services Reform (Scotland) Act 2010, abolishes NHS Quality Improvement Scotland and creates Healthcare Improvement Scotland (HIS). In addition to the development of scrutiny within the NHS, HIS takes on the scrutiny of independent health care previously carried out by the Scottish Commission for the Regulation of Care. It is not expected that these changes will directly impact on the delivery of the current work programmes of NHS QIS. 7

8 SECTION 2 RECOMMENDATIONS Following the series of bi-lateral discussions which took place during late 2008, and a discussion with the NHS Board Chief Executives in March 2009, meetings were held with the collective group of Special Health Board Chief Executives and also with the Chairs to consider the emerging findings and recommendations of the review in the current context of reducing resources, and the continued priorities across NHSScotland of improving health, reducing health inequalities, improving healthcare quality and establishing a mutual NHS. As a result of this consideration, it was agreed that the report should focus on three key issues and make recommendations covering the interfaces between Special Health Boards, with the Scottish Government, and with other NHS Boards. Improving communication and information sharing Maximising economies of scale and reducing duplication Improving leadership and collaboration It was apparent during the discussions that Special Health Boards had already started, or were in the process of planning, a range of initiatives to deliver more effective services and better value for money. These initiatives form the basis of a number of the recommendations in this report. A number of these initiatives highlight the importance of Special Health Boards working closely with Territorial Boards and other stakeholders in order to develop and secure improvements. Moves to extend joint working has been an increasing feature of the activity of Special Health Boards and some examples of the benefits of this approach are included in this report. 8

9 Recommendation 1 : Improve Communication and Information Sharing One of the striking outcomes of the review exercise itself was the opportunity it gave to Special Health Boards to meet together, to share information about the services they provide, the challenges they face, the action they are taking, their visions and goals and the opportunities they see to improve the value they add, and the economies of scale they can achieve. This exercise of information sharing allowed Boards to identify some areas of for potential synergies, best practice sharing and mutual learning which individual and groups of Special Health Boards agreed to explore immediately. It was agreed that this report itself would be an important opportunity to set this information out in sufficient, but accessible and consistent format and detail, to act as source material for carrying out a wider exercise of information sharing and communication across NHSScotland, the Scottish Government, and the wider public sector and Third Sector. The issue of annual planning, target setting and performance management through the Local Delivery Planning process was discussed in the first stage of the review. It was agreed that Special Health Boards should each include the core process HEAT targets within their Local Delivery Plans, and, recognising the distinct functions and roles of each Special Health Board, that they should additionally agree separately a limited set of additional targets and commitments with the Scottish Government as part of the Local Delivery Planning process. Each Special Health Board s LDP would also reflect that Boards responsibility to support the wider NHS to achieve the full range of HEAT targets and Government outcomes. It was also agreed that Special Health Boards have a responsibility to communicate and agree with Scottish Government all variations to their annual Local Delivery Plans. Special Health Boards should continue to include the core governance HEAT targets in their annual Local Delivery Plans, to reflect their responsibility to support the wider NHS in the achievement of the full range of HEAT targets and to develop and agree with SGHD an appropriate suite of specific performance targets. The section on Leadership and Collaboration below sets out recommendations which will support a stronger link between the lead contacts on the Special Health Boards and Scottish Government which will support this. Specific Recommendations 1.1 The detailed description of the role, functions, opportunities and visions of each of the Special Health Boards in this report is used to promote ongoing communication between Special Health Boards, Territorial Boards, Regional Planning Groups, the Scottish Government and the wider public and voluntary sector. 1.2 The Scottish Government supports a regular collective meeting for the Chief Executives of the Special Health Boards to assist the Special Health Boards in collectively agreeing how they can contribute to, and respond to specific national issues and initiatives. 1.3 Special Health Boards and Scottish Government Health Directorates need to ensure that Management Statement / Financial Memoranda are in place, are appropriately signed off, and are reviewed regularly. 1.4 Special Health Boards should continue to include the core governance HEAT targets in their annual Local Delivery Plans, to reflect their responsibility to support the wider NHS in the achievement of the full range of HEAT targets and to develop and agree with SGHD an appropriate suite of specific performance targets. 1.5 Through an outcome driven approach Special Boards will work together and with Territorial Boards in support of the wider high level Scottish Government outcomes and determine how best to prioritise and align activities of ensure that maximum impact is made on the related high level targets. 9

10 Recommendation 2 : Maximise Economies of Scale and Reduce Duplication Through increased communication and information sharing, there will be new opportunities to identify existing and emerging areas of activity across NHSScotland, within Scottish Government and in the wider public and Voluntary Sector where greater economies of scale or value added could be achieved. Special Health Boards have already begun addressing this bilaterally, and are committed to eradicating any duplication. The review concluded that, through shared commitment across Special and Territorial Boards, there was potential to explore the scope for more efficient use of administrative and capital resources in the current context of tightening resources and increasing demand. Opportunities to secure economies of scale include: bi-lateral arrangements between Special Health Boards to share activities and resources in order to, make maximum use of scarce skills; Special Health Boards individually, or collectively, identifying a service which they can provide or support nationally in order to deliver higher levels of quality, efficiency and effectiveness; Territorial Boards identifying further opportunities to make optimum use of the services which Special Health Boards are best placed to provide. Barriers to effective joint working include lack of communication and understanding of what the services Special Health Boards do or could offer; limited experience or expertise in joint working, and lack of time or priority given to developing inter-board solutions. It is clear that these barriers are being addressed, but there would be value in extending and accelerating this process. Specific Recommendations 2.1 Special Health Boards and Territorial Boards should work together with the Scottish Government to identify and agree areas where services could be provided and activity carried out more efficiently and effectively through a shared national focus on quality. 2.2 Special Health Boards to continue to work together and with other Territorial Health Boards nationally, regionally or locally, to realise the benefits of the economies of scale, reduction in duplication and higher levels of quality which are identified and agreed through recommendation (2.1). These opportunities include maximising opportunities for joint appointments, resource sharing and joint procurement/tender initiatives. 2.3 Territorial Health Boards and SHBs should more systematically consider opportunities for collaborative working to make more effective use of SHBs capacity and expertise. 10

11 Recommendation 3 : Leadership and Collaboration There is a wide range of initiatives and improvement developments progressing across NHSScotland at any time, many of which are linked/related, and many having implications and impacts for a number of Special Health Boards. The review concluded that there was clear scope for increasing the quality of these developments and the resultant delivery of services by reviewing the scope and timing of the involvement of Special Health Boards. These improvements would be possible by Scottish Government and Territorial Health Boards establishing more systematic approaches to involving Special Health Boards agreeing which Special Health Boards are most relevant to any particular issue, and establishing effective approaches to engaging with them. This would also require clarity about which individual and/or organisation was leading in the consideration./development of any issue, and a responsibility for them to establish appropriate plans and methods for collaborating with all other relevant stakeholders. Specific Recommendations 3.1 Each Special Health Board should be enabled to play a full, and where appropriate individual, role in the development and delivery of regional and national services and service developments through representation on the relevant groups and subgroups. 3.2 Steps should be taken to ensure the sustainable effectiveness of the sponsorship role of Scottish Government officials working with individual SHBs through the establishment of appropriate job descriptions with time allocations and training/development support, where required. Consideration should be given to the development of a training programme for SHB sponsors. 3.3 Patient/public involvement must reflect the nature of customer relationships enjoyed by Special Health Boards. Boards with direct consumer relationships with the Scottish public should follow the PFPI processes that pertain to Territorial Boards. 11

12 ANNEX A NHSSCOTLAND SPECIAL HEALTH BOARDS : DETAILED DESCRIPTION OF ROLES, FUNCTIONS AND OPPORTUNITIES The pages in this section set out in some detail the role, functions and future opportunities for each of the 7 Special Health Boards and NSS. This material is intended to be used as a basis for Special Health Boards to communicate bilaterally and collectively with all potential SGHD, NHS and wider public and voluntary sector customers and partners, to explore potential areas for identifying economies of scale and reducing duplication, as well as in delivering more effective, higher quality health services. Table 1 provides a succinct summary of their key purpose. NHS 24 NHS Education for Scotland (NES) NHS Health Scotland National Waiting Times Centre (NWTC) NHS Quality Improvement Scotland (QIS) Scottish Ambulance Service (SAS) NHS National Services Scotland (NSS) The State Hospitals Board NHS 24 provides timely information and guidance on health needs, appropriate treatment and access to services and resources for the people of Scotland. Its core role is providing patients with advice and triage during the out-of-hours period when GP surgeries are closed. NHS Education for Scotland develops educational solutions for workforce development by designing, commissioning, quality assuring and, where appropriate, providing education for all staff groups in the NHSScotland workforce. NHS Health Scotland provides leadership and works with partners to improve health and reduce health inequalities in Scotland. NHS NWTC manages the Golden Jubilee National Hospital and the Beardmore Hotel and Conference Centre and provides a range of surgical specialties to support delivery of waiting times. It also manages National Heart & Lung services and the West of Scotland Heart & Lung Centre one of the largest units in the UK. NHS Quality Improvement Scotland supports NHSScotland in the delivery of: consistently high standards of care and equity of access; improved outcomes for patients; better experiences for patients and carers; best use of resources; and supports NHS staff in the provision of effective clinical practice and service improvements The Scottish Ambulance Service provides comprehensive accident and emergency and non-emergency ambulance services for the whole of Scotland. NHS National Services Scotland provides a range of national and specialist services which enable and support improvements in the health and wellbeing of Scotland's population. The State Hospitals Board provides assessment, treatment and care in conditions of special security for individuals with mental disorder who, because of their dangerous, violent or criminal propensities, cannot be cared for in any other setting. The Hospital is a national service for Scotland and Northern Ireland. 12

13 NHS 24 Current position Role and functions of the Board NHS 24 is responsible for the delivery of clinical assessment and triage, health advice and information by telephone and online services providing the population of Scotland with care 24 hours a day, 365 days a year. Specifically, the role of NHS 24 is to: triage calls, assess patients symptoms and refer patients to the most appropriate healthcare professional within an appropriate timescale based on clinical need; work in partnership with local health systems provided by NHS Boards, NHS staff organisations and local communities through integration with other parts of the NHS - in particular, the GP Out-of-Hours Services provided by NHS Boards throughout Scotland, the Scottish Ambulance Service and the Acute Hospitals Accident and Emergency Departments; support the health improvement agenda across Scotland by working in partnership with local Boards to provide added value services where and when required, utilising the IT telephony and infrastructure to benefit patients 24 hours a day; provide other telephone-based and online Health Information and Advice Services e.g.: the NHS Helpline, a national health information service; the Healthy Living Advice Line, which currently provides advice on diet and physical activity; the Breathing Space Service, which provides support for people suffering low mood and depression the recently launched Care Information Service, which provides Community Care information for older people. This includes both national information, such as that published by the Scottish Government Health Directorates and the Care Commission, and information about locally delivered services. The unscheduled care service receives over 1.5 million calls per year. Recent Developments In addition to the unscheduled care service, NHS 24 is now the first point of contact for patients requiring emergency dental services in the out of hours period, providing assessment of symptoms and arranging face to face clinical treatment if needed, thus unifying the access for the unscheduled dental care, and providing Boards with a standard, efficient entry point to the dental out of hours services. NHS 24 are currently delivering a pilot telephone based Cognitive Behavioural Therapy (CBT) service ( Living Life ), in partnership with five Health Boards, for people referred by their GP for help with mild to moderate depression, which provides talking therapies to patients who may otherwise have difficulty accessing CBT services due to rural location or social deprivation. NHS 24 has developed its local presence across Scotland in order to provide more locally sensitive healthcare delivery. Local services are now in place in all mainland Health Board areas, and with implementation of a centre in Orkney underway. NHS 24 are currently delivering a pilot Brief Intervention service ( Taking Measure ) with one Health Board in order to provide advice and referral to services for callers with harmful or hazardous alcohol use. This service will complement NHS Boards target of achieving an 13

14 agreed number of screenings using setting-appropriate screening tool and appropriate brief intervention, in line with SIGN 74 guidelines by 2010/11 (Heat target H4). The website continues to be developed with the focus remaining on the delivery of information about health and health services, as well as supporting a number of national health campaigns during the year including meningitis awareness and cervical screening, and cervical cancer immunisation. The website received over 940,000 visits during 2008/09. Callers suffering from low mood or depression who contact NHS 24 can now be directly transferred to the specialist helpline advisers in the Breathing Space service who also provide advice, guidance and further information on other statutory or voluntary agencies available in the caller s local area. Prior to this development, NHS 24 Nurse Advisors would be required to deal with these calls (which can be substantially longer than calls to the core service). This development means that callers are dealt with by the most appropriate resource, and ensures that the core service makes efficient use of its Nurses. Without the Breathing Space service itself, callers would either need to be dealt with by the core NHS 24 service, dial 999, or self present at Accident and Emergency departments. NHS 24 has continued to develop the roles of our staff in order to use their range of skills in order to provide patients with the most appropriate advice, and to provide a more efficient use of resources, for example: o people contacting the service with certain low clinical risk conditions (such as earache, scalds, bites and stings) are provided with assessment and advice by highly trained call handlers under robust clinical governance and real time clinical supervision; o patients contacting the service with medicine related calls are now directed to a pharmacist for advice; o people contacting the service with dental symptoms are now directed to dental nurses for further advice; o NHS 24 now employs mental health nurses within the service, and is in the process of appointing a mental health lead for the organisation. NHS 24 carries out Equality and Diversity Impact Assessments on all services (existing and new) to ensure they provide measurable equality of access to and experience of the services for all of Scotland s diverse communities of people, and the organisation continues to evolve and embed partnership working with our patients, service users and people from the major equality communities, to help improve services in response to patient feedback and views. Significant Planned Activities NHS 24 were asked by Scottish Government Health Directorates to take forward the development of the National Health Information and Support Service ( NHS Inform ) in order to provide access to consistent quality assured information about health and health service in Scotland. The service will be delivered online, by telephone via the NHS Helpline, and by direct access through Citizens Advice Bureaux, Community Pharmacies, Libraries etc. NHS 24 was approached by the Primary Care Division of the Scottish Government Health Directorates to develop a business case for the delivery of a health self assessment programme for the residents of Scotland. This health check will be offered to people on or around their fortieth birthday, and is one of a number of health checks identified in the Better Health, Better Care Action Plan. The purpose of this service will be to focus on raising awareness of health and wellbeing and the key role an individual has in taking responsibility for their own health. The service will also provide information to the user on the prevention and early detection of illnesses and conditions that mainly affect the 40-plus age group e.g. diabetes and heart disease. A pilot will be launched in May

15 NHS 24 has commenced a major project with the Scottish Ambulance Service to develop a common triage tool in order to ensure that patients contacting both services receive a standard assessment, regardless of which service they contact initially. From the 1 st April 2010, NHS 24 will take over responsibility for the Scottish Centre for Telehealth, from NHS Grampian. The two organisations are currently developing a Strategic Framework which will detail the key programmes of activity for the SCT over the next two years. Key Achievements During 2009, NHS 24 further enhanced the unscheduled care service, with the implementation of the Call Streaming project, so that those patients who require to be called back can be provided with an indicative call back time. NHS 24 has been central to the delivery of NHS Scotland s response to the current outbreak of Influenza A (H1N1), working closely with the Scottish Government, Health Boards, Department of Heath, and NHS Direct, to offer a Scotland-wide solution. With the outbreak of H1N1 Swine Flu, NHS 24 carried out a number of activities to provide an interim Fluline service to the people of Scotland. This included activities such as increasing the resources available to the service; updating the current messaging system presented to callers to the service; implementing a dedicated team of staff to deal specifically with related queries; commencing work to expand the capacity of the messaging system; and commencing work to implement an algorithmic based Interactive Voice Recognition service to take callers through a number of yes/no questions in order to provide them with an appropriate outcome, including self care, contact pharmacy, or transferred automatically into the core NHS 24 Service. In addition, the NHS 24 website has been continually updated with information specific to the situation, and continues to be updated as new information becomes available. NHS 24 remains actively engaged in the planning of Scotland s longer term response to an outbreak of pandemic influenza. During 2008/09 NHS 24 implemented a virtualised emergency dental service delivery model, where dental nurses now manage patients from all Health Board areas. Previously dental nurses only managed patients from one, or a few, Health Boards Areas. An inbound telephony model was implemented in November Prior to this date, all dental calls were managed as return-calls to patients. Patients in the Glasgow and Clyde area benefit from the increased knowledge and understanding that has resulted from the innovative project co-locating the West Emergency Medical Dispatch Centre for the Scottish Ambulance Service; NHS Greater Glasgow and Clyde s Primary Care Out of Hours; and the NHS 24 Glasgow and Clyde service together in one clinical area. A similar model has now been implemented in the East with the recent move of the East Emergency Medical Dispatch Centre for the Scottish Ambulance Service to co-located premises in South Queensferry. Interfaces Scottish Government Membership of NHS Scotland Out of Hours Operations Group, ehealth programme and the Emergency Access Delivery Team; Regular performance meetings held with SGHD; Representation on groups such as Shifting the Balance of Care leads, Long Term Conditions team 15

16 NHS Boards Developed Clinical Governance links between Health Boards including the development of clinical performance indicators spanning the patient journey, being piloted for stroke; Representation on Regional and National Planning Groups; Working with Forth Valley, Greater Glasgow and Clyde, Lanarkshire and Lothian Health Boards to implement the recommendations of the NHS Scotland Maternity Telehealth Project, where a joint implementation group has been established and a bespoke education and training programme for midwives has been developed, with the first group of midwives completing their training in February 2009; Hosted eight help lines for Health Boards in Scotland over the past year - these special help lines are designed to give the public information, reassurance and in some cases provide assessment at times of a public health incident for example an outbreak of Tuberculosis, Ecoli, Legionnaires disease; Supported the GP Access Survey by managing the advice line linked to this survey to support patients completing the survey either by post or online; NHS 24 has been working closely with the national Keepwell initiative determining how the staff, telephony and IT infrastructure can support the key aims of the project in order to provide a more efficient service. Specifically engaging with NHS Lothian, NHS 24 worked with three practices requiring support with telephone engagement for parts of the community identified as being at risk of developing coronary heart disease or diabetes. 739 out of 1247 patients were successfully contacted (nearly 60%), with appointments made for almost 50% of those patients. In total, almost 490 hours of resource time was used. NHS 24 is initiating telephone contacts for 2000 patients from four further Lothian based practices. A joint working group is also being established with NHS Grampian in order to determine the most appropriate NHS 24 services to be delivered from the new Emergency Care Centre in order to deliver the most efficient unscheduled care service. NHS 24 developed and provided a bespoke education and training programme for physiotherapists and launched a telehealth physiotherapy triage and referral management service in January 2009, which offers a single point of access to physiotherapy services within NHS Lothian. This new service was developed in partnership with the Scottish Government Health Directorates, NHS Lothian and NHS 24, and utilises NHS 24 s technology and allied health professionals expertise to provide a physiotherapy telephone advice and onward referral management system service for patients. NHS 24 has been participating in the development of the NHS Grampian social marketing pilot campaign ( Know Who to Turn To ) to educate the public of Scotland about the various unscheduled care services, and when they should be accessed. Special Boards A joint working group has been established between NHS 24 and the Scottish Ambulance Service consisting of the Chairs, Chief Executives, two Non-Executive directors, and an Executive Director from each organisation. A number of joint initiatives have already taken place, and a further number are now underway, including: o the transfer by the SAS of Category C calls to NHS 24 (i.e. those 999 calls that, following initial assessment by the SAS, do not need an ambulance response) these calls are subject to regular clinical audit to ensure appropriateness. o the move of the East EMDC to Norseman House, and the reconfiguration of the existing co-located services in the Inverness EMDC to provide a similar environment to Cardonald. The use of shared facilities not only improves the patient journey, but provides significant efficiency savings and value for money for NHS Scotland as a whole. 16

17 o investigations into the development of an integrated clinical triage system, which would provide patients contacting either service with a standard assessment. o the development of a joint target for the assessment and transfer of patients identified as suffering from a Hyperacute Stroke. Worked with NES to deliver the new National Health Information Support Service (NHS Inform). Implemented six monthly Executive Team meetings between NHS 24 and NHS Direct. Public Sector Working with the Care Commission to improve communication between care home and NHS 24 staff, particularly in the out of hours period, which will support a more consistent, efficient initial assessment process for residents in the care home environment. Formal processes for objective setting and reporting In 2009 we published our 3 year Strategic Framework Delivering and Moving Forward, aligned to Better Health Better Care which will guide the delivery and development of NHS 24 s services for the next three years, from 2009/10 to 2011/12. To support delivery of the Strategic Framework, NHS 24 now has an annual Corporate Plan which establishes the corporate objectives for the year, including those contained within our Local Delivery Plan. Our Local Delivery Plan is established in conjunction with the SGHD Performance team to agree the specific objectives for the organisation each year. The Executive Team is accountable and responsible for reporting against the strategic objectives outlined in the Corporate and Local Delivery Plans. Budgets and Workforce (changes over 3-5 years) Budgets Year Capital Resource Limit (000s) Revenue Resource Limit (000s) 07/08 6,277 55,646 08/09 1,546 57,102 09/10 1,608 58,210 Workforce2 Year Workforce (FTE) 07/08 1, /09 1, / As contained in workforce plan 17

18 Other Opportunities to Add Value Supported Self management schemes for patients with Long Term Conditions Continued support for Local Boards in provision of anticipatory care programmes such as Keep Well Continued work with local authorities, social care and the voluntary sector in order to move towards delivering single outcomes Expansion of the remit of our mental health specialists Ensure that NHS 24 s contact centre expertise is utilised to support the procurement and delivery of public sector helplines Continued development of local presence by developing our services in partnership with Health Boards Provide direct access to outpatient and GP next day appointments, or direct admission to inpatient wards during the out of hours period where appropriate Identifying ways in which we can help provide better access to healthcare information and services in remote and rural communities Develop reputation as a Research organisation, making use of research by working with the Emergency Access Delivery Team in order to gain a better understanding of why people contact us; and to provide more preventative care Provide greater support to recently discharged Armed Services personnel in accessing health services Carry out appointment reminders and both pre and post hospital assessments to ensure that patients scheduled for in-patient care are still able to attend, and to provide help to patients who have recently been discharged Continued expansion and improvement of the range and depth of our online health information at nhs24.com and the services provided by the Health Information Advice telephone service Use our technology to expand the ways in which we provide information and services to people by considering different means of delivery, e.g. via the internet, chat rooms or text Use of the Palliative Care Summary data to ensure that patients calling us can be provided with care in their home if appropriate Increasing the use of remote consultation and diagnostics through telemedicine and telecare Actions or changes required by others - Increased awareness of our current and potential future role within the NHS in Scotland in terms of supporting the delivery of HEAT Targets Improving Services Improving Health Economies of Scale Minimising duplication NHS 24 only NHS 24 and others 18

19 NHS Education for Scotland ROLE AND FUNCTION NHS Education for Scotland (NES) is the national health board with responsibility for the education and development of the NHS Scotland workforce. Our mission is to design, commission, quality assure and where appropriate provide education for the NHS in Scotland. NES was formed in 2002 through the merger of three previous bodies who had responsibility for the organisation and funding of post graduate training for doctors and dentists; pharmacists; and nurses and midwives. Since then NES has extended its remit to cover all other groups in NHS Scotland including Clinical Psychologists, Healthcare Scientists and Optometrists. Since its formation NES has played a key strategic role in providing educational infrastructure for all healthcare staff through innovative developments such as the e-library and the e- portfolio; we have also been able to reap the benefits of multi professional working which has been particularly valuable in the development of new roles, challenging traditional boundaries. We are accountable to SGHD for the post-graduate training of target numbers of key professionals including doctors and dentists, and we hold the base salaries for these posts which ensures that training capacity is protected in the face of service pressures and enables us to implement key policy directives such as Modernising Medical Careers on behalf of SGHD. ADDING VALUE IMPROVING SERVICES NES improves services through ensuring that NHS Boards have access to the trained professionals which they need to deliver, improve and modernise their services; and that health professionals can access continued development to enhance their contribution. Over the last three to five years NES has substantially expanded the number of trainees which it supports; NES has worked in partnership with NHS Boards and professional and regulatory bodies to develop roles such as non medical endoscopists, assistant practitioners in radiography, and physician assistant (anaesthesia). These roles allow NHS Boards to effectively deploy staff to improve the services that they offer; NES has substantially increased educational infrastructure, with examples including the development of the e-library, and the clinical skills strategy; and NES has adopted a tailored approach towards supporting health professionals in remote and rural parts of Scotland. Examples of this approach include the establishment of RRHEAL (Remote and Rural healthcare educational alliance); the mobile clinical skills unit; and the programme of outreach taking dental students into teach and treat centres across Scotland. Critically NES also works with NHS Health, NHS Quality Improvement Scotland and NHS National Services Scotland to ensure that our activities complement each other. ADDING VALUE IMPROVING HEALTH In addition to its work in training key clinical professionals, NES contributes to the health improvement and health inequalities agenda on a number of levels: providing materials to assist healthcare workers in their understanding and appreciation of health inequalities; providing educational support directed at addressing many of the consequences of health inequalities; and building relationships with the wider social care network to help to ensure a joined up approach to these issues. One example is the way in which NES has worked with stakeholders to develop and deliver education and training for Dental Health Support Workers and Extended Duty Dental Nurses to support families in the home and to bridge the gap between families at high risk of poor oral health and the dental care team, breaking the destructive cycle in deprived areas of only accessing services when in pain. By March 2009 NES had delivered training to 310 Extended Duty Dental Nurses and 133 Dental Health Support Workers. 19

20 ADDING VALUE ACHIEVING ECONOMIES OF SCALE From the very start, the formation of NES enabled economies of scale to be achieved and synergies of educational experience and best practice to be realised. It should be acknowledged that Aspiring to Excellence, the report of Sir John Tooke s independent inquiry into Modernising Medical Careers and the recruitment problems of 2007, recommended the establishment of Medical Education England a body which the report argued could fulfil for England, the role played by NES in Scotland. NES is uniquely placed in the health service in the UK to act on behalf of NHS Boards and to achieve economies of scale by commissioning education and training for healthcare staff. This approach has the advantage not only of being able to aggregate demand and thereby achieve a better price, but also of ensuring transferability of learning across Scotland and between NHS boards. For example, in response to the urgent need to reduce Theatre Lists, NES commissioned a major three year HPC regulated programme to prepare Operating Department Practitioners and provide two sustainable cohorts to NHS Scotland. ADDING VALUE MINIMISING UNNECESSARY DUPLICATION OF INVESTMENT AND EFFORT NES has also taken the lead in identifying areas where it can play a role in achieving economies and avoiding duplication, particularly in relation to educational infrastructure where developments such as the e-library and the e-portfolio have provided a resource for staff and trainees across Scotland in a way which would not otherwise have been possible. We recognise that there are potential overlaps between our role and that of NHS Health in providing training, and NHS 24 in providing patient information, and we work closely with both organisations to ensure that we are supporting and complementary in our approach. We have recently agreed to provide support to the Scottish Ambulance Service in their review of the way in which they provide education and development for their staff. RECENT 3 5 YEARS DEVELOPMENTS The last 3 to 5 years have been characterised for NES by significant expansion in both existing and new business areas. This has been driven by demand from the service (for example for new role development); by policy priorities (such as the Dental Action Plan) and by UK wide initiatives (for example the implementation of modernising medical careers). The work which NES has done in developing staff roles including consultant nurses and AHPs, practitioners with special interests, advanced practitioners, and healthcare support workers lays the foundations to allow NHS Boards to think about delivering services with a different skill mix. Much of this development has been supported by additional funding; in other areas NES has made best use of its core funding to radically improve educational infrastructure for NHS staff groups that have not been particularly well served in the past (e.g. Practice Education Facilitators). The introduction of modernising medical careers has had an enormous impact on NES in the last few years. We have played a critical role in managing the transition; and crucially in avoiding what could have been a crisis when the UK wide recruitment process collapsed in At this point NES acted decisively to put in place an alternative system to ensure that job offers went out and doctors were in place for August. 20

21 PLANNED ACTIONS AND ORGANISATIONAL CHANGE Future developments for NES will be strongly influenced by the publication of A Force for Improvement the workforce response to Better Health, Better Care. NES is solely or jointly responsible for a number of action areas set out in this document. At the same time NES will continue to deliver on its core business in relation to the production of trained professionals; to extend its influence in areas such as support for Healthcare scientists and Optometrists, to commission national education programmes and to play an important brokerage role at a UK level in relation to UK regulated health professionals. During 2009/10 NES will take over from SGHD responsibility for the performance management of undergraduate nursing.provision; and will need to continue to work very closely with Scottish Funding Council (SFC) in this regard. Another particular organisational pressure for us in 2009/10 will be the commitment required from NES and NHS Boards in preparation for the Postgraduate Medical Education Training Board (PMETB) visits in The next few years will be particularly difficult for NHS Scotland in the face of a significant decline in public expenditure. NES will continue to take a long term view and seek to protect the education and development of staff which is critical to sustainable, safe services. We believe that in this environment, it is more important than ever that we are able to play our part in ensuring that best value is achieved across Scotland in the commissioning, delivery and governance of education and development for healthcare staff. To this end we will seek to work increasingly closely with NHS Boards to ensure that developments are streamlined, best practice is shared; and that learning is transferable, and wherever possible, credit rated. ACHIEVEMENTS A FEW EXAMPLES In NHS staff from across all NHS Boards in Scotland graduated from the first national Postgraduate Certificate in Frontline Leadership and Management. The successful graduates work in NHS first line management patient care and service delivery roles and have undertaken the programme to develop their leadership and management skills as a key element of the NHS Scotland Leadership Development Framework. NHS Education for Scotland developed the programme in partnership with De Montfort University and UHI Millennium Institute and is supporting 400 bursaries over the first three years to enable frontline NHS staff to take an active leadership role in healthcare delivery. The programme is structured to enable working professionals to apply their learning directly through short study days and extensive on-line learning. As a result of the programme participants have commented on improved confidence in working with colleagues and leading service improvements for patients. The case studies in the programme illustrate examples of participants effectively collaborating with colleagues to take forward change and sharing ideas to develop areas of their practice. The Dental Action Plan has been a major development for NES over this period and has accounted for a significant element of the increases in budget and in staffing. NES has delivered a wide range of workforce development initiatives in conjunction with NHS Boards, which are now successfully improving access to NHS dental services in Scotland. Prime examples include four new Oral Health Therapist courses, thirty additional Dental Vocational Training places, twelve new teach and treat centres and over 300 in-practice courses for decontamination. Other initiatives in support of NHS Boards include a new clinical effectiveness programme, basic and specialist training for dental nurses and practice staff and training for dental technicians. The e-library development (now knowledge services) was initiated by NES in 2003 and has gone from strength to strength. It is a prime example of how NES can use its position as a national board to provide services more efficiently than they can be provided on a local, board by board basis. The e-library provides access to electronic journals, books and other materials to all NHS Staff in Scotland, and has recently been extended to provide 21

22 support to the social care sector. NES also continues to work in the area of information literacy and in the provision of support to specialist groups which include rehabilitation professionals, cancer care workers and administrative and clerical support staff. Flying Start, a web based development programme for all newly qualified NMAHPs in Scotland was launched by NES in 2006 and has now been taken up by all NHS Boards. Over 9,000 of NHS Scotland s newest staff have benefited from the on-line learning resources, peer discussion forums and support from work-based mentors. This development assists new practitioners in making a successful transition from student to registered practitioner, enabling them to create an individual reflective portfolio enhancing their lifelong learning skills, whilst providing vital evidence of meeting the requirements for the KSF and professional regulation. NES Practice Education Facilitators support Flying Start NHS mentors locally by offering expert advice and guidance to improve the learning environment across NHS Scotland. They encourage local ownership of a national resource, empowering new practitioners to be self-directed learners in the vital first year of practice as a registered health practitioner. NES developed the education framework to support the recommendations of the SGHD review of Senior Charge Nurses. Staff in this key role the lynch pin of clinical care in ward based hospital provision and key to reduction in HAI and improved quality of patient experience are now benefiting from NES support to implement the framework in a manner relevant to their local circumstances. The HAI Education Initiative was formed by NES in 2003 to support prevention and control of Healthcare Associated Infection in response to all elements of the HAI Task Force Action Plans.( ) A range of educational resources have been developed in areas relating to Patient Safety, Decontamination, Tissue Viability, Antimicrobial Prescribing and Infection Prevention and Control. Almost 6000 staff, across all disciplines and professions, have accessed a stand alone Hand Hygiene module and a further 7952 staff have completed the Cleanliness Champions Programme including 2595 G Grade nurses across NHS Scotland. This Cleanliness Champions Programme is now part of the curriculum in undergraduate courses in nursing and midwifery; medical; dental and healthcare related programmes INTERFACES NES works through a model which is driven by mutuality and interdependency and our working philosophy is that of partnership. We respond to both service requirements and policy drivers and we often occupy the middle ground brokering agreement among different bodies; whether it be developing roles that challenge traditional boundaries or reacting swiftly where UK wide policy initiatives present challenges and a whole Scotland approach is required (e.g. MMC). Our process of strategic engagement with NHS Boards operates through senior named contacts to complement the strong uni-professional arrangements, and is key to our understanding of the workforce development requirements of NHS Boards. We also draw on intelligence from workforce plans and our awareness of UK and national developments which will impact on services for example in advance of the introduction of MMC we sought to alleviate pressures on NHS Boards through ensuring that support was in place to develop Hospital at Night teams. Through the challenges of the last few years we have maintained and strengthened relationships with the Royal Colleges and other professional bodies, with the Scottish Funding Council, Universities Scotland, Scotland s Colleges, the Scottish Social Services Council, Skills for Health and with the regulatory bodies, including GMC, HPC, GDC, NMC; and importantly PMETB, on whose behalf we act to assure the quality of post graduate medical education in Scotland. 22

23 The relationship with the Scottish Funding Council (SFC) is particularly important in ensuring that we are able to join up further and higher education provision with the requirements of the health service. We have an agreed joint action plan with SFC and the benefits that have emerged from this include: the provision of the new Scottish Clinical Physiology degree programme, the provision of 100 new funded student places for remote and rural initiatives; and the Score Project: a radical curriculum review of Honours level Nursing and AHP degree programmes. We are also working closely with the Scottish Social Services Council particularly in the areas of public sector workforce development for services for children and elderly people. Critically NES is able to act at a national, a UK and an international level on behalf of NHS Scotland. As an example in this area the NES developed e-portfolio is now used by foundation doctors not just in Scotland but across the whole of the UK. Increasingly strong interest in using NES products such as the e-portfolio and the cleanliness champions programme is being expressed from a number of non UK countries and NHS Flying Start (the web based development programme for all newly qualified NMAHPs) is poised to be rolled out across the UK, and into other countries. BUDGET AND WORKFORCE The NES budget has increased by 19%, or 59 million, over the period from 2005/6 to 2007/8 and we have also seen growth across our workforce. BUDGET: The growth in the NES budget relates both to developments in the business which we inherited from our predecessor organisations and to new business for which NES has assumed responsibility. In addition to inflationary pressures the resource increases have supported the following significant additional investments: Increased Activity 000s Increase of 40 or 15% in GP Registrars 3,000 An increase of 225 or 5% in the number of training places for post graduate doctors. 9,500 Supporting the new GP curricula with ST1s spending 6 months in practice 10,000 Increase (over and above inflation) in Medical ACT payments 4,600 An increase of 30 postgraduate dental training places 1,000 Meeting all our targets under the Dental Action Plan 14,000 Taking over the management of the pre-registration pharmacy scheme, including the transfer from SGHD of the management of 160 trainee salaries Expansion of training routes for clinical psychologists, including masters degree provision The development of roles including; non medical endoscopists; operating department practitioners; physician assistants; assistant radiographers, senior charge nurses, GPs and practitioners with special interests Establishing the clinical skills managed educational network, the mobile clinical skills unit, and Rheal Establishing the AHP and NMAHP Practice Education Facilitator infrastructure 4,000 2,500 1,000 Investment in e-library and knowledge services 1, ,350 23

24 WORKFORCE: The growth in both the scope and the size of our business has inevitably resulted in staffing growth as our infrastructure has had to keep pace with developments. Staffing growth has been particularly high in the following areas: Dental the responsibilities allocated to NES under the Dental Action Plan and supported by additional recurrent funding of 14 million account for 35% of the total NES staffing increase over the period 37 WTE posts. The increasing involvement of NES in mainstreaming NHS Flying Start, practice education and the Cleanliness Champions programme, in project based work supporting role development, responding to SGHD policy initiatives, managing regional workforce projects and extending our scope in areas such as admin and clerical and finance staff has required additional staffing resource and accounts for an additional 25 WTE posts. The workload referred to above, together with other developments requiring specific expertise resulted in a substantial increase (32 WTE) in net inward secondments to NES over the period. The requirement for additional posts in HR, Finance, IM&T and other support areas accounted for an additional 11 posts; this included an increase of 4 posts which was due directly to NES being subject to the relocation policy and therefore requiring in this period to staff additional office space in Glasgow as an advance base. Due to the nature of our work and the volume of project based activity around 20% of NES total staffing establishment is on fixed term contracts or secondments. REPORTING ARRANGEMENTS In common with all NHS Boards, NES produces an annual Local Delivery Plan which contains around 50 of our key targets for the year. These are targets that are identified as being particularly important in supporting NHS Boards deliver their HEAT targets and the NES LDP maps each target against the standard NHS Board HEAT targets. In addition to this LDP we produce an annual Corporate Plan which sets out the full range of our objectives and is signed off by SGHD. All our LDP and Corporate Plan targets are monitored via our performance dashboard with regular monitoring through the Finance and Performance Management Committee which reports to the NES Board, which is attended by our sponsor. These reports are also considered at meetings of the NES round table sponsor group. All the NES Directors work closely with their Chief Professional Officers at SGHD and NES is also fundamental in a number of key governance groups such as the Speciality Recruitment Delivery Board. 24

25 NHS Health Scotland CURRENT POSITION Role and contribution NHS Health Scotland is a Special Health Board with a national remit. We play an important role in improving the health of everybody living in Scotland, and tackling inequalities in health. Improving health among the most disadvantaged and those who experience discrimination, involves effecting change both in the way that services are delivered and the environment in which they are delivered. Our intention is to be a national advocate for health improvement and the national partner of choice for organisations requiring advice, help and support on health improvement and health inequalities. We strive to be a leading source of expertise on what is needed to improve and sustain health, including changes in society, organisations and individuals. Given the breadth of issues related to tackling the determinants of health, we work with a very wide cross section of policy, development and delivery partners: local government, NHS Boards, Scottish Prison Service, community and voluntary sector etc. Our work adds value to the Scotland Performs framework, helping cross-sectoral interests to recognise and deliver on a shared commitment to health outcomes. Major recent deliverables illustrating this contribution include: Health Improvement Performance Management developmental and capacity building support, Green Exercise Partnership with Scottish Natural Heritage and Forestry Commission, Curriculum for Excellence Health and Wellbeing content development. Added value The prime focus of Health Scotland s work is improving health and reducing health inequalities and this clearly determines the content of our work. Thus all of our outputs relate to the theme of improving health. Our specific functions are set out below and the related areas of added value will cut across the themes of improved services, achieving economies of scale and minimising unnecessary duplication of effort and effort as follows: Building skills and support networks of staff, in all sectors in Scotland, whose roles incorporate public health improvement and tackling health inequalities. We provide national Health Improvement networks such as the Physical Activity and Health Alliance and the Wellbeing in Sexual Health Alliance (akin to national clinical networks) which offer practitioners from all parts of Scotland opportunities to share recent learning for practice development. Our support ensures that high quality infrastructures are widely available, and reduces the risks of patchy and possibly inconsistent systems developing across Scotland. Our national learning and development function provides quality assured, low cost, impact assessed and policy relevant training to multidisciplinary groups. We complement the work of NHS Education for Scotland (NES) by provision of health related training to many non-clinical groups. Our training focuses on support for the delivery of the H HEAT targets. In addition to delivering training, we provide an infrastructure to monitor quality aspects and to provide a wider health improvement and inequalities perspective to core health workforce planning. The national provision by Health Scotland enhances comprehensive coverage, quality assurance and reduces duplication. 25

26 Providing specialist advice to support Scottish Government public health improvement and health inequalities policy-making, informing the planning of how this policy might be delivered in practice by a range of agencies, and influencing the design and delivery of health services to help ensure major service strategies improve health and prevent disease. The input we provide assists in quality assurance and in maximising deliverability. Disseminating and explaining relevant public health improvement and health inequalities evidence, learning and good practice, to professional and public audiences, maximising reach, understanding and impact through using the most effective media, language and timing. The key benefits are reduced duplication and more comprehensive and consistent approaches to service delivery. Supporting marketing linked to local health improvement services and facilitating the integration of local marketing approaches with the national strategy, when appropriate. Our national communications team are matched as named contacts for local NHS Boards and work to provide specialist support for local health improvement communications. For example, in undertaking development and delivery of the national smoking cessation programme, Health Scotland delivered a national advertising campaign, driving people to a national helpline, whilst at the same time supporting local boards to promote their local cessation services through a series of local roadshows and other locally tailored approaches. Benefits include provision of additional resource, and improved synergy resulting from more effective linkage between national programmes and local implementation. In addition to our health improvement communications support, we are the key provider of communications support to Health Protection Scotland (for immunisation activity) and to NSS for national screening programmes. Working closely with NHS 24 as the online portal, we produce items of print for patients/the public in Scotland. We are the major source for high quality health improvement resources which we provide at cost price (and where possible free). Enhanced quality, efficient use of expertise and reduced duplication of effort are key benefits. Evaluating agreed aspects of Scotland s public health improvement and health inequalities national programmes, and supporting evaluation of local activity, where needed. It is more efficient to undertake evaluations of national policy/ programmes at national level, whilst the local support builds longer term sustainability and quality of planning. Reviewing published research and commission new research on innovations, insights and evidence on public health improvement and health inequalities, and assembling timely, accurate and accessible resources from this work, so that we are the preferred source of current knowledge for Scottish stakeholders in these fields. National reviews reduce duplication and increase quality and efficiency. Providing a source of expertise, via the Equalities and Planning Directorate, with a clear imperative to support Health Boards in Scotland, including other Directorates in Health Scotland, reduce health inequalities, promote equality and achieve better outcomes for patients. Providing nationally consistent but locally tailored support drives up quality and is efficient. 26

27 Key changes/improvement over the last 3-5 years The organisation has undergone significant changes. Since its establishment in 2003 from the merger of the Health Education Board for Scotland (HEBS) and the Public Health Institute of Scotland (PHIS), there has been a major expansion of the organisation in order to achieve additional economies of scale and achieve benefits of centralised co-ordination, leadership and quality improvement in key areas of health improvement policy. For example, the organisation s incorporation of Choose Life has provided significant efficiency savings in suicide prevention training courses. A new Directorate of Equalities and Planning was created in 2008 following a major consultation exercise, replacing previous work on the Fair for All equalities strands, and incorporating the National Resource Centre for Ethnic Minority Health (NRCEMH). In 2005, Scotland's Health at Work (SHAW) and Safe and Healthy Working (SaHW) were brought together under the new umbrella of the Scottish Centre for Healthy Working Lives, and formally integrated within Health Scotland. Scotland is the first country within the UK to have taken forward this critically important work through a single national centre. The service in Scotland comprises Scotland's Health at Work national award programme and a Healthy Working Lives telephone advice line offering free and confidential expert advice on workplace safety and health to individuals and employers. It provides free impartial and confidential workplace assessment visits to help companies understand their Occupational Health and Safety duties and provide practical and workable solutions for small firms. A range of webbased services are also provided. We have made concerted and coordinated improvements to customer service in recent years, undertaking customer surveys and agreeing improvement action plans in partnership. In 2005 we created a Partnership Management Programme and have been working to continuously develop and improve this approach since then. Through this programme, we have a named senior manager to act as a point of liaison with each local board. Our aim is to maximise the effectiveness of NHS Health Scotland s and local NHS Boards' contributions to achieving the shared outcomes of improving health and reducing health inequalities. Much of our work is programme and project based and it is important that we can articulate how we can achieve project goals, engage with partners whilst showing how individual projects, team plans and programmes interconnect and contribute to corporate objectives. To this end we have made significant advances in internal business planning, reporting and performance management processes, including investment in a new Business Planning Tool, enabling enhanced financial and project planning. In relation to organisational development, we have embarked upon a leadership programme in recent years allowing for the support of directors and managers Interfaces Our primary focus is to work with local NHS Boards and health improvement partners during the implementation of public health improvement and health inequalities programmes, as well as other initiatives designed to achieve health outcomes. These will help meet public health HEAT targets, embed equality and diversity, and address local priorities, therefore supporting national outcomes in Single Outcome Agreements (SOAs). At local level, we work with NHS Boards and their community planning partners. Nationally, and as an advocate for health improvement, we share robust evidence and expertise with a wide range of people and organisations: special health boards, local authorities, equality and voluntary organisations, and business and professional bodies. We also seek to influence the news agenda and policy makers in support of improving health and reducing health inequalities, based on government priorities. 27

28 Our partnerships seek to achieve agreed common aims, and maintain close working relationships across key areas of work. The Partnership Management Programme, referred to above, promotes shared learning, effective communication, better alignment of planning, delivery and reporting. The programme has a dedicated senior manager and co-ordinator who works with 14 of NHS Health Scotland s senior managers, each of whom have taken on the role of partnership manager for a particular health board. The partnership managers provide information, updates and advice as required by their allotted health board. Feedback from Boards is used to inform our future plans and activities. The Partnership managers also work very closely with NHS Health Scotland's Head of Corporate Communications and Director of Equalities and Planning to ensure that all our communications and planning is aligned. Communicating health messages to the general public is central to what we do. We speak to individuals within their social context, right at the beginning of the development of initiatives, in order to develop a deep understanding and insight into the customer. This way, we make sure all our messages and marketing materials are designed to best meet the needs of those who will use them. Sometimes these materials are distributed by our partners, and sometimes by us, depending on what works best. We have working relationships with key Scottish Government colleagues including our formal sponsor (Business Manager), complemented by extensive engagement and collaboration with policy leads within the Government with whom we agree specific parts of our Corporate Framework and annual Business Plan. Our engagement with the Community and Voluntary Sectors is an essential part of our work and happens in many ways and at many levels, including through the programmes and projects managed by our Equalities Support Team, and the Programme Design and Delivery Directorate. We have commissioned the Scottish Community Development Centre (SCDC) and the Community Health Exchange (CHEX) to deliver 'Healthy Communities: Meeting the Shared Challenge' which is a national capacity building support programme for community-led health approaches. This support programme was commissioned by the Scottish Government s Health Improvement Strategy Division as a way of ensuring the co-ordinated implementation of the Community-led Task Group recommendations. The 'Meeting the Shared Challenge' support programme has been rolled out across the whole of Scotland. The programme seeks to ensure that the contribution of community health initiatives to delivering local and national health improvement outcomes is better understood and clearly demonstrated to commissioners. Local Authorities are in a strong position to contribute significantly to the reduction of health inequalities by improving the life circumstances of the communities they serve. We therefore manage a Local Government Programme which is instrumental in further developing relationships and health improvement activity with the Convention of Scottish Local Authorities (COSLA) and other national local government organisations and agencies, to support councils and Community Planning Partnerships. The Programme works in close partnership with COSLA, SOLACE and other partners to support community-led health improvement activity. At a UK level we have strong links with the National Institute of Clinical Excellence (NICE), a range of public health and health promotion networks and professional connections with a numerous academic institutions through funding and commissioning arrangements. On an international front, we have the status of a World Health Organization (WHO) Collaborating Centre in recognition of our expertise in health promotion and public health development. In addition to Scotland playing its part in contributing to international development there are potential benefits to Scotland in collaborating in international health improvement projects, including monitoring trends through international co-operation, sharing of information and experiences. 28

29 Interface with Territorial Boards In addition to the engagement described above, which captures part of the generic ways and levels at which we interface with territorial boards, there are specific engagement plans for all programmes and in relation to the Overview the Specialist Public Health Function. In relation to organisational and professional development we are also developing a programme of shortterm secondments and shadowing. Interface with Special Health Boards We have a wide range of engagements and relationships with Special Health Boards in order to add value to mutual agendas around key areas of national policy impacting on health improvement, health inequalities and NHS Scotland as an efficient and patient-centred system. For example, we work closely with NHS Education for Scotland (NES) in relation to Health Improvement / Health Inequalities Learning and Development. We work in partnership with NHS 24 in relation to the provision of online health improvement information and as a distribution channel or point of access for key messages and resources around, for example, anticipatory care alignment and topic specific helplines, such as Breathing Space, and alcohol interventions. Our connections with NHSQIS include work on the development and implementation of Scottish Intercollegiate Guidelines Network (SIGN) guidelines, work in support of assessment and in developing the national suicide register, as well as work with the Scottish Health Council to support the Equality and Diversity aspects of Patient Focus and Public Involvement (PFPI). We have strong connections with NHS National Services Scotland (NSS), particularly via the Information Service Division, including key developments around screening, developing equalities intelligence and the Scottish Public Health Observatory (ScotPho) partnership with important outputs such as the publication of Community Health Partnership (CHP) profiles. In addition, we have a Memorandum of Understanding with Health Protection Scotland to underpin positive partnership working in areas of environmental health and immunisation. Formal processes for objective setting and reporting We deliver and support a huge range of integrated projects (c.400 in 2009/10 for example) and their contribution to agreed corporate objectives is outlined in our Business Planning Tool. We work collaboratively with Scottish Government colleagues each year to agree the high-level strategic priorities for delivery, and have an internal and external system of quarterly reporting to the Board, its sub-committees and range of high-level working groups. The Corporate Management Team is accountable and responsible for reporting against the strategic objectives outlined in the Corporate Framework and Business Plan. Budgets and workforce (changes over 3-5 years) Revenue resource limit ( k) Capital resource limit ( k) Cash requirement ( k) Staff numbers (WTE) 2003/ / / / / /09 13,969 17,148 19,672 22,595 23,091 25, ,768 16,000 20,000 22,000 23,062 25, c.300 The table above provides a clear picture of the scale of organisational growth and change which the organisation has undergone in recent years. As outlined elsewhere, most of this growth reflects the requirement for the organisation to incorporate other bodies and create new 29

30 efficient delivery structures, building on existing economies of scale and pertinent infrastructures to support national strategic priorities, such as the healthy working lives agenda and equality and diversity in health. There has also been significant development and growth of Health Improvement-related policy core to BHBC, Equally Well, new smoking and alcohol legislation, transformations around food in schools etc. All such policy developments require implementation support. Selected examples of achievements Social Marketing (Impact of HPV Work) Post implementation evaluation of the HPV campaign has been extremely positive. In particular: awareness of HPV rose from 17% to 70% among year olds and their parents/carers. 70% direct traffic to website and nearly 4 pages viewed each visit. Above industry average CTR 0.24% on Google search. Vaccine uptake figures released in Feb 2009 have been very high amongst S2, S5 and S6s - Dose 1: 93% and Dose 2: 87%. This has meant that every local Board has benefited from the same high quality communications support that has made local service delivery uptake easier to achieve. Patient information (Scale and demand for publications) We have had a positive partnership with Alzheimer Scotland to update and redesign two publications: 100,000 Worried about your memory, 40,000 Facing dementia were printed and disseminated. We have also reprinted and disseminated 80,000 copies of Coping with dementia. These resources have been crucial in supporting local boards to equip their frontline staff (and those in training) with high quality patient information around this important HEAT target. The latter resource is now being used as far afield as Japan. Networking and partnership development (growth in key areas that respond to new policies such as Commonhealth legacy) In 08/09, the Physical Activity & Health Alliance (PAHA) extended its reach across a broad range of staff that could help develop physical activity, with membership up 25% to PAHA provided opportunities for members to network (national conference with 400 attendees), share learning and good practice, and inform future policy development (a series of regional events were delivered for local partners). Energising Lives was introduced to improve knowledge, enhance practice and ensure consistency of message in Primary Care; the new Active Scotland website will raise awareness of local opportunities to be physically active. Membership no s, website traffic, event attendance, and positive feedback tell us that there is a high level of engagement from the PA workforce, and that PAHA continues to meet their needs. Active Scotland has received unprompted and unequivocal praise from users, and has been given considerable prominence within the Commonwealth Legacy planning process. The respective networks have had tangible impact:- strengthened policy (Green Exercise Partnership), operational synergy (Girls & Young Women Reference Group), sharing of resources (NHS/PA Special Interest Group). The unique contribution which HS can make to 2014 health legacy planning has been clearly defined, and future involvement will reflect this. Supporting integrated and multi-disciplinary action on health inequalities Caring About Health: an A-Z Health Resource for staff and carers of looked after children has been distributed to all relevant health professionals, residential care establishments, foster care services and social workers in Scotland. Due to demand, the resource has undergone a further print run and revision. Research has been carried out which profiles health improvement initiatives taking place in residential care homes for children and young people. 30

31 The A-Z resource has been very well received by partners. The main impact of this work has been to increase health related information for staff and carers, strengthen the communication between health professionals and social care staff and encouraging the involvement of staff and carers in the health improvement agenda relating to looked after children. Involving stakeholder partners in developing and updating the A-Z resource is seen as a key learning point for this work. In addition, local distribution was undertaken by LAAC nurses and this has enabled health professionals to engage directly with residential care managers and foster carers and clarify why and how the resource should be used, thereby maximising its impact at local level. POTENTIAL NEW DEVELOPMENTS This section sets out some proposals for development improvements at various levels: Coordinated planning: when new national programmes of work/action plans are developed it would be beneficial to involve as appropriate the special/national Boards that have a role in quality assurance, development and support for implementation during the period in which such plans are being created. This would be with a view to ensuring that any support infrastructures that are required are available when needed. Joint planning: we would suggest setting up with other special/national Boards (NES, QIS, NSS, NHS 24) a planning and review group (or similar) with a national membership, of which the Director of Planning equivalent and key Executive Delivery posts might possibly form the core, with agreed TORS, agendas, action trackers etc. Health improvement HEAT targets: we would recommend that NHS Health Scotland convene delivery support groups for the H target areas with the involvement of NES, QIS and NSS, and NHS 24, along with service delivery partners. This would be aimed at adding even greater value towards territorial Boards objectives around for example, alcohol, anticipatory care, smoking cessation and so forth. Health Improvement Performance Management: the system which we have developed, based on logic modelling, has already attracted significant interest within the field and in terms of its applicability to wider settings of public sector service delivery. We could potentially expand our role in supporting learning and development and capacity building in this area in a way that is intrinsically supportive of community planning processes and the further development of outcome-based models. This could possibly connect into further collaborative work with NHS Education for Scotland and NHS Quality Improvement Scotland to support the wider primary care system and Community Healthcare Partnerships in developing and delivering contributions towards Single Outcome Agreements. Wider future collaborations: NHS Health Scotland works with a wide range of partners outside the NHS. We could build upon existing work to include partnerships with other national agencies around the National Outcomes, for example Sports Scotland, Scottish Natural Heritage, Learning and Teaching Scotland, the Food Standards Agency. In turn we could explore how these links could be exploited more widely with NHS partners. We could potentially play an increased role in the Community and Voluntary sectors, providing valuable support towards the development of gold-standard service agreements that deliver on health-related outcomes as well as capacity building or consultancy-style support. The strategic review of the Scottish Centre for Healthy Working Lives could provide a number of opportunities to increase the impact and reach of the work further still, adding significant value to population wellbeing as well as business efficiency during a challenging economic period. We could potentially play an increased professional role in the development of Social Enterprise, increasing the benefits to health and wellbeing that this can bring. 31

32 NHS National Waiting Times Centre ROLE AND CONTRIBUTION Role and functions of the Board The NHS National Waiting Times Centre is made up of two distinct parts - the Golden Jubilee National Hospital and the Beardmore Hotel and Conference Centre. About the Golden Jubilee National Hospital Based in Clydebank, near Glasgow, the Golden Jubilee was established as Scotland's flagship hospital for reducing patient waiting times. We receive referrals from across the country for a range of surgical specialties. The hospital is home to a large Orthopaedic Centre of Excellence, the West of Scotland Heart and Lung Centre, the National services of Advanced Heart Failure & Transplantation, Adult Congenital Cardiac & Pulmonary Vascular Services making it one of the largest specialist centres in the UK. Clinical Services Cardiac Surgery Thoracic Surgery National Heart & Lung Services Anaesthetic and Intensive Care Diagnostic cardiology Interventional cardiology Orthopaedic surgery General surgery Ophthalmic surgery Plastic surgery Minor and day case procedures Endoscopy Diagnostic Imaging Services X-ray Magnetic Resonance Imaging (MRI) scanning Computer Tomography (CT) scanning Bone densitometry Barium exams Ultrasound The Beardmore Hotel and Conference Centre The award-winning four-star Beardmore Hotel and Conference Centre is committed to delivering excellence in health, hospitality and learning and is the national NHS and public sector conference facility. How we have improved services We have to date performed almost 200,000 inpatient, day case and diagnostic imaging procedures since 2002 (when purchased by the Scottish Government) helping reduce patient waiting times across Scotland. We have integrated heart and lung services from four sites into one, four years ahead of schedule. The Golden Jubilee now provides regional and national heart and lung services in one state of the art centre. We undertake see and treat initiatives allowing a one stop shop for patients that avoid repeat visits to different hospitals and reduces outpatient waiting times. We have reduced the length of stay (LOS) for Orthopaedic hip and knee replacement patients, the Golden Jubilee now has the shortest LOS in the country. Expanded our orthopaedic services due to demand within NHSScotland, helping reduce waiting times across the country in that specialty. Agreed to establish a Bariatric regional service for 3 WOS Boards during 2010/11. 32

33 How we have improved health We continue to maintain very low rates of Healthcare Acquired Infection and the Golden Jubilee was the first hospital in Scotland to implement MRSA screening for all inpatients. One of two specialist centres in the west of Scotland that provide the Optimal reperfusion service providing better outcomes for patients who have a heart attack as a result of a blocked artery. In 2007/08, the Golden Jubilee National Hospital carried out 10% of all cataract operations undertaken by NHSScotland. In 2008/09, we carried out 18% of all hip and knee replacement operations undertaken by NHSScotland (40% equivalent in the West of Scotland). Established an innovative anaesthetic multi-modal approach to Orthopaedic post operative rehabilitation (Caledonia technique) leading to reduced length of stay. Follow up Orthopaedic Arthroplasty service ensures continuity of care. Direct GP referrals for imaging procedures leading to faster diagnosis for patients. How we have achieved economies of scale Introducing extended roles in areas where there is (inter)national shortage of skills (e.g. anaesthetic and surgical practitioners). Centralised patient booking system for appointments. PFPI and equality and diversity agenda under one umbrella group Involving People Steering Group. Use of Beardmore Hotel and Conference Centre as a pre-op and step down facility. In 2005/06, NHS and public sector accounted for only 12% of total Beardmore business, and in less than three years, this has grown to 40%. The Beardmore Hotel and Conference Centre is now one of only two venues in Scotland accredited as a Conference Centre of Excellence. It has also received the Green Tourism Silver award. In 2009, the Beardmore was named 'Business Hotel of the Year' by Hotel Review Scotland. How we have minimised unnecessary duplication of investment and effort Direct referrals through the see and treat initiative, where a territorial Board pass on patients to us for their whole pathway pre-assessment, surgery and outpatient appointments. Involvement in shared services. Sharing of images to NHS Boards (e.g. Angiograms). Joint tenders with other Boards to increase efficiency. Joint procurement with other Boards (e.g. heart valves). Facilitating and delivering electronic information flows across the West of Scotland in relation to supporting heart and lung patients. KEY CHANGES/IMPROVEMENTS OVER THE LAST THREE TO FIVE YEARS West of Scotland Heart and Lung Centre The new regional centre is now fully operational, four years ahead of the original proposal. And as at 1 April 2008 the management of the Heart and Lung Service and assets transferred from NHS Greater Glasgow and Clyde and NHS Lanarkshire to the Board. 33

34 Spread over four floors of the Golden Jubilee National Hospital, facilities at the centre include seven theatres and four cardiac catheterisation labs special x-ray rooms for diagnosis and treatment of blood vessel blockages around the heart. From April 2008 the Golden Jubilee National Hospital has provided: All adult heart and lung surgery for the West of Scotland, including all bypasses, heart valve surgery and other complex procedures. Interventional cardiology services, including angioplasty, angiography, electrophysiology and complex pacemakers. National services: o Scottish Advanced Heart Failure Service, including the heart transplant unit o Scottish Pulmonary Vascular Unit o Scottish Adult Congenital Cardiac Service (SACCS), previously known as the Grown-Up Congenital Heart unit (GUCH). In 2008/09, the Optimal Reperfusion service was rolled out for patients across the West of Scotland. This meant that patients who have a heart attack as a result of a blocked artery will now be treated at two specialist centres in the West of Scotland, the Golden Jubilee National Hospital (GJNH), Clydebank and Hairmyres Hospital in East Kilbride. Expansion of our Orthopaedic service Orthopaedic surgery remains the specialty providing the biggest challenge in regard to meeting waiting times commitments for the Health Service in Scotland. The Golden Jubilee National Hospital is committed to responding to the Orthopaedic requirements of all NHS Boards across the country. By January 2008, the Golden Jubilee National Hospital had successfully opened two new ultra clean laminar flow theatres taking our total number to four. To help us expand the service, we also created an additional 20 ward beds and appointed an extra three full time consultants as well as a range of nursing and other healthcare workers. This has helped us carry out just under 3,000 orthopaedic procedures in 2008/09 compared to just over 1,600 in 2006/07. In 2008/09 we carried out 18% of all Hip and Knee replacements for NHSS. Expansion of diagnostic services In 2008/09, we performed just under 15,000 diagnostic imaging procedures and reduced time to appointment for patients from eight weeks to four weeks to integrate with the 18 week referral to treatment (RTT) guarantees. Through the heart and lung and orthopaedic expansions, the department has taken on new duties including 24 hour on-call for a number of modalities and extended working days. Prior to the recent expansions, we upgraded our radiology department. This ensured we improved the quality of examination and diagnosis, increased scope of service by providing a comprehensive range of imaging procedures, improved dynamic imaging; and improved archive facilities. Due to this, activity increased 77% in 2005/06 compared to 2004/05. Our recent expansion can be summarised in the below table. Before After Theatres 5 14 ICU/HDU 8 46 Cardiology beds 8 32 Cath Labs

35 Staff (headcount) Revenue (total) 35m 104m Capital 2m 9m Advances in orthopaedics The Golden Jubilee is leading an initiative that allows joint replacement patients to be back on their feet within hours of surgery (Caledonia technique). By using a variety of techniques to allow this to happen (positive attitude and not using general anaesthetic), patients can be discharged as early as day two or three after surgery. The hospital is also pioneering the use of computer assisted orthopaedic surgery. Currently, only two per cent of surgeons use this technique. The benefit to surgeons is that it helps them do exactly what they need to; it s much more precise, and helps them position the implant right down to the last millimetre. This provides major benefits for patients as they have a reduced chance of complications arising from using this technique. Beardmore Hotel and Conference Centre The Beardmore was established as a national NHS and public sector centre of excellence for conferences, meetings and training in May Since then, use of the facility has grown significantly. In 2005/06, NHS and public sector accounted for only 12% of total Beardmore business, and in less than three years, this has grown to 40%. Technology The NHS National Waiting Times Centre is a pilot site for the nationally procured theatre system (OPERA). This will ensure maximisation of theatre scheduling, which will in turn support increased patient throughput. The Board was also one of the first sites to implement the national Picture Archive Communication System (PACS), and has just completed the largest Intensive Care Unit (ICU) deployment of the Clinical Information System (CIS). The Beardmore Hotel and Conference Centre has introduced imacs to every bedroom within the venue. In the future this will allow delegates, patients and staff to access specific information on an individual basis such as surgery information for patients, rota information for staff etc. Research and Development In December 2007, our Research Manager established robust research governance processes to manage research projects hosted by the Board and to deal with the transfer of projects associated with the West of Scotland Heart and Lung Centre. Since then, the total number of projects registered with the Board has increased to 46, with 24 in the active recruiting phase, and 22 in the set up phase (May 2009 figures). We are expanding this programme to generate in excess of 500k income per year for NHS Scotland. Examples of success Since purchase have undertaken almost 200,000 inpatient, day case and diagnostic procedures for patients across Scotland. In 2008/09, we carried out 18% of all hip and knee replacement operations undertaken by NHSScotland. This also represents 40% undertaken by the West of Scotland hospitals. Integration of heart and lung services from four sites into one, four years ahead of schedule (2008 versus 2012). In 2008/09, the Optimal Reperfusion service was rolled out for patients across the West of Scotland. This meant that patients who have a heart attack as a result of a blocked artery will now be treated at two specialist centres in the West of Scotland, the Golden Jubilee National Hospital (GJNH), Clydebank and Hairmyres Hospital in East Kilbride. 35

36 In 2007/08, the Golden Jubilee National Hospital carried out 10% of all cataract operations undertaken by NHSScotland. This also represents 23% undertaken by the West of Scotland hospitals. Continues to maintain low rates of Healthcare Acquired Infection. Housekeeping report to Infection Control Manager. Have pioneered the Caledonia technique and now have the shortest length of stay for patients undergoing hip and knee replacements in Scotland. Successfully met the national 4% sickness absence target in March In 2008/09 achieved financial balance and exceeded our efficiency target. We exceeded the national HEAT target regarding KSF based PDPs in March In 2005/06, NHS and public sector accounted for only 12% of total Beardmore business, and in less than three years, this has grown to 40%. The Beardmore Hotel and Conference Centre is now one of only two venues in Scotland to be accredited as a Conference Centre of Excellence. It has also received the Green Tourism Silver award. In 2009, the Beardmore was named 'Business Hotel of the Year' by Hotel Review Scotland. Achieved the silver Healthy Working Lives award. Interfaces Scottish Government : Margaret Duncan, Delivery team (our performance manager) John Connaghan, Director of Delivery (sponsor) Mike Lyon, Delivery Team NHS Boards Delivery of activity/service level agreements (SLAs) with territorial NHS Boards Operational relationship with service managers West of Scotland cardiac and thoracic planning Membership of regional, national planning and working groups Colleague/peer networks (Director of Finance meetings etc) Ongoing relationships with SAS and NSD through service delivery. NES to support our education framework for postgraduate and undergraduate clinical and non-clinical education Emergency and Continuity Planning with NHS Greater Glasgow and Clyde Rotational training of staff (e.g. dieticians) Public sector: Discharge planning relationship with 20+ Local Authorities Chief Executive on the Board of Clydebank Rebuilt Other links Founder member of the Glasgow Heart and Lung Institute along with the University of Glasgow. The centre will provide the best of medical and surgical care, unparalleled teaching and training opportunities, seamless integration of basic, clinical and public health research and the rapid transfer of research discoveries into new diagnostics, prevention and treatments to achieve direct benefits for the Scottish population. Peer links to Papworth Hospital, and to South West London Elective Orthopaedic Centre for benchmarking purposes. Relationship with several Scandinavian health systems to initiate good practice and continual improvement. 36

37 International medical links such as Computer Assisted Orthopaedic Surgery - CAOS International and other clinical networks. Strathclyde Partnership for Transport (SPT) for public transport access planning. Volunteer, charities and other support organisations (Involving People work). Budgets and workforce Budget ( 000s) WTE Note 2005/06 48, /07 53, (a) 2007/08 66, (b) 2008/09 99,123 1,280.7 (c) Based on figures as in m12 finance report. (a) Rise mainly due to inflation and an increase in patient numbers. In 2006/07, we delivered 31,912 procedures, which was 4% above target and 11% more than the previous year. (b) In 2007/08, there was a change in funding with an agreement to move to 90% allocation arrangements. In addition, there was a significant increased activity within Orthopaedics due to opening two new theatres. (c) The budget and workforce during this year increased due to the transfer of heart and lung services to the Board from NHS Lanarkshire and Greater Glasgow and Clyde. Associated income was also transferred. The Board has successfully achieved all financial targets and has delivered efficiency savings in excess of plan. Formal processes for objective setting and reporting To ensure robust scrutiny, the Board has a Performance and Planning Committee, chaired by the Chief Executive, which meets on a monthly basis to receive and scrutinise the operational performance of the organisation, and ensure all activities are aligned to Local Delivery Plan (LDP) objectives. This committee reports to our Senior Management Team (SMT) and thereafter the Board through a balanced scorecard approach. In line with SGHD guidance issued in 2007, we developed a performance management framework which linked NHSScotland s objectives with our Local Delivery Plan (LDP). Our LDP forms the basis of our corporate objectives which are then cascaded throughout the organisation through Personal Development Plans of individuals and departments. Generally, our performance management framework consists of: regular collection and reporting of rigorous, accurate, relevant data; analysis of this data to provide an accurate and timely view of activity and outputs that support progress towards well-defined outcomes; regular review and discussion of this data at monthly (or more frequently) scrutiny meetings led by the Chief Executive focusing on the data and actions required to improve performance; and active follow-up from data findings and meetings, overseen by the Senior Management Team (SMT). 37

38 Directorate teams led by General Managers deliver ongoing developments to ensure full multidisciplinary involvement, engagement and communication. This has ensured clear accountability for performance and resource utilisation as well as clinical governance. A Performance and Planning department was established using existing staff to contribute to the strategic direction of the organisation, further develop our performance management systems, oversee performance monitoring and reporting for the Board, lead/coordinate key projects and participate on behalf of the Board on national Performance and Planning Committees. The Board s performance framework has received excellent reviews from both internal and external audit scrutiny. FUTURE ACTION How we can continue to improve services Action/Proposal National and regional planning needs to actively factor in our potential capacity on a long term sustainable basis, not just on a yearly basis Expand the range and number of direct referrals to the Golden Jubilee Hospital. Increase involvement with the Healthcare Policy and Strategy Directorate to ensure that current and potential role of Board is integrated fully within the NHSS. Continue to work closely with the Scottish Ambulance Service (SAS) in relation to urgent heart attack patients and transport issues Responsible party SGHD/Territorial Boards/NWTC SGHD/NWTC/Territorial Boards SGHD/NWTC NWTC/SAS How we can continue to improve health Action/Proposal Exploration of specialties that can be provided on a regional and/or national basis (for example bariatric surgery). Investigate other specialties that have a clinical fit with services already provided at the NHS NWTC The Orthopaedic centre of excellence at the Golden Jubilee has the potential to expand capacity and range of services it offers. Expansion of cardiac training, research and innovation to ensure centre of excellence rating. Development plan for the use of ventricular assist devices (VADs) not just as a bridge to heart transplant but also as a destination therapy. Responsible party NWTC/SGHD/Territorial Boards/National and regional planning fora NWTC/SGHD/Territorial Boards SGHD/Territorial Boards/NWTC NWTC/University of Glasgow NWTC 38

39 Increased referrals to the national heart failure service Explore shifts between surgical and interventional activity within heart and lung services (for example Trans-catheter Implantation) Potential to offer diagnostic services as part of obligate networks to support remote and rural communities Territorial boards/nwtc NWTC Territorial Boards/NWTC How we can achieve more economies of scale Action/Proposal Investigate possibility of NHS 24 call handlers to assist Golden Jubilee patients regarding appointments (during quiet periods). Support for the development of our clinical skills and research centre a resource that will benefit all of NHSS. Continue to work on a regional and national basis to support effective and efficient patient pathways Continue redesign and new initiatives to support 18 week RTT Responsible party NWTC/NHS 24 Territorial Boards/SHBs Territorial Boards/NWTC/National and regional planning Territorial Boards/NWTC How we can continue to minimise unnecessary duplication of investment and effort Action/Proposal Explore further ways of sharing services, for example around the equality and diversity agenda Explore the potential for joint appointments/ sharing of resources in areas where there is a lack of expertise (e.g. economists) or potential for split site working (e.g. general surgeons) Continuation of joint tender/procurement initiatives Responsible party All Boards All Boards/SGHD NWTC/Territorial Boards/SHBs 39

40 NHS Quality Improvement Scotland 1. ROLE AND CONTRIBUTION OF NHS QIS NHS QIS leads the use of knowledge to promote improvement in the quality of healthcare for the people of Scotland. We perform three key functions: we provide advice and guidance on effective clinical practice, including setting standards we drive and support implementation of improvements in quality, and we assess the performance of the NHS, reporting and publishing our findings. Advice, guidance and standards Assessment, measurement and reporting Integrated cycle of improvement Implementation and improvement support Assurance Accountability Local improvement cycles Our functions can be presented as an integrated cycle of improvement. Within this remit we have central responsibility for patient safety and clinical governance across NHSScotland. In addition, the Scottish Health Council, the Scottish Intercollegiate Guidelines Network (SIGN) and the Healthcare Environment Inspectorate are part of NHS QIS. We take a lead role in coordinating the work of the Scottish Patient Safety Programme and provide support to the Scottish Medicines Consortium. In 2008 it was announced that a single scrutiny body for health would be established, bringing together the existing functions of NHS QIS with the independent healthcare functions of the Care Commission. The new body, Healthcare Improvement Scotland, will be established in

41 1.1 Improving services Providing healthcare is complex and, as well as interventions specific to a disease, a number of different factors need to work well together to delivery quality in individual patient care. We published clinical governance and risk management standards to support the development of the underpinning systems needed to make sure clinical services are safe, effective and patient focussed. These standards also support quality improvement. We have also focused on specific clinical services, under the following key themes: cancer, cardiovascular disease, long-term conditions, maternal and child health, mental health, vulnerable groups, primary care and community healthcare and patient safety. 1.2 Improving health Our aim is to drive improvement in the quality and safety of healthcare for the people of Scotland, by focusing on improving patients outcomes and experience, based on the best available evidence. By implementing NHS QIS advice the service will maximise its contribution to the health and well being of the people of Scotland in the areas of targeted activity. In relation to health improvement specifically and the reduction of inequalities, we deliver a range of outputs relating to the key challenges identified in the Better Health Better Care Action Plan and subsequently Equally Well. 1.3 Achieving economies of scale We are developing and implementing integrated programmes of work in support of the priorities of NHSScotland which encompass each of our functions in a cycle of continuous improvement. This will maximise the impact of both our work and the response of NHS Boards on patient care. Programmes have been developed: o internally (e.g. HAI, stroke, CHD, mental health, maternity services) o with other Special Health Boards and Scottish Government (e.g. SG and NHS Education on nutritional care; Information Services Division on national datasets aligned to our standards and SIGN guidelines) o with other agencies e.g. Audit Scotland on long-term conditions. 1.4 Minimising unnecessary duplication of investment and effort We provide advice and guidance to NHSScotland on the clinical effectiveness of a wide range of health interventions (clinical guidelines, health technology assessments, evidence notes, new drug appraisals (SMC), NICE appraisals). Cost effectiveness is also taken into account in key pieces of work. NHS QIS advice and guidance promotes reliable and consistent healthcare and outcomes and supports NHS Boards to focus on what works. We participate in multi-agency review, regulation and inspection arrangements, with a particular focus on vulnerable groups, which maximise levels of assurance and reduce duplication through a risk-based proportionate approach. Through the work of the Scottish Health Council, a co-ordinated approach to local and national patient focus and public involvement activity is taken, avoiding unnecessary duplication of assessment. Our clinical governance work contributes to the wider integrated governance agenda (Good Governance for Health) while working with Audit Scotland to avoid duplication of activity. 41

42 2. RECENT DEVELOPMENTS Strategic Direction NHS QIS was established in 2003 from a merger of 5 (later 6, with the addition of SIGN in 2005) separate healthcare quality improvement organisations. In 2006 we commissioned an evaluation of our impact. Since then we have reviewed our strategic direction to further integrate and streamline our activities and to focus on supporting NHSScotland to implement our advice and recommendations, through the introduction of an integrated cycle of improvement. Work programme Introduction of a themed work programme to demonstrate more clearly our contribution to NHSScotland priorities such as cancer, heart disease and stroke, and mental health and to maximise our impact, with a stronger focus on implementation and improvement support for NHS Boards. To support this and increase transparency, we have also significantly changed the way that we develop our work programme, including the establishment of a Programme Board. Since 2007 we have undertaken national co-ordination of the Scottish Patient Safety Programme to drive new and different ways of improving quality and reliability within NHS QIS and across all NHS Boards. We have participated in multi-agency review, regulation and inspection. NHS QIS has published national standards for clinical governance and risk management, and for the first time been reviewed against these, and has established ongoing monitoring arrangements. In 2009 we have established the Healthcare Environment Inspectorate, which will carry out site visits to every Scottish acute hospital. We have broadened our Patient Focus and Public Involvement activity, both through our Public Partners and by developing additional models of engagement, increasingly working with voluntary and community organisations. 3. ACHIEVEMENTS As outlined above, NHS QIS approach now comprises an integrated cycle of improvement, linking the three main components of our remit in programmes of work to maximise impact on patient care. This is in its relatively early stages of development, however the following provides an example of how this approach can and will continue to add value: Stroke Performance reviews in 2006 highlighted three key areas of recovery: swallowing (dysphagia), speech (aphasia) and early mobility (ankle-foot orthosis). We have developed a range of practical tools and guidance to support front-line staff, including a best practice statement on ankle-foot orthosis, recommendations to improve the delivery of services to people with aphasia; an update and merger of SIGN guidelines on stroke; and a rapid review of the NHS QIS stroke standards to reflect the revised SIGN guideline. Nutritional Care NHS QIS published standards for Food, Fluid and Nutritional Care in 2003 and reviewed performance against three of the standards in The reviews highlighted the need for an improvement programme particularly in relation to nutritional assessment, screening and care planning. In response to this a broader practice development programme providing support and resources for Boards has been put in place, as part of the work of the National Multi- Agency Programme Board on Nutritional Care. 42

43 Coronary Heart Disease In 2007 we published five SIGN guidelines relating to different aspects of the prevention and management of CHD. A multidisciplinary group was established to increase the involvement of healthcare professionals in their implementation, including provision of educational tools. Using the evidence contained within the guidelines, we have reviewed current standards on CHD secondary prevention and have embarked upon a programme of national audits based around the guidelines. Other examples of the impact of individual NHS QIS outputs are: Scottish Woman-Held Maternity Record all pregnant women in Scotland now carry a copy of this record to ensure consistency across primary and secondary care. HTA on screening for MRSA the HTA recommended a pilot project on the implementation of patient screening; this is now underway. Clinical Standards for Diabetes following an initial round of performance assessment reviews in 2003, we focused on supporting Boards to address some of the key issues identified, and in follow-up reviews in 2006, found that every Board had improved the quality of care provided. 4. KEY INTERFACES Scottish Government Regular meetings with sponsor division as well as with other policy, medical and nursing divisions in SGHD. A Management Statement and Financial Memorandum between NHS QIS and SGHD is in place. NHS QIS is represented on a range of SGHD working groups both general and topicspecific [e.g. Better Together, Children and Young People s Health Support Group, Delivering for Mental Health Implementation Board] and the work of NHS QIS is integral to a number of national delivery and action plans, including workstreams within Better Health, Better Care. NHS Boards NHS QIS works with all NHS Boards, providing them with advice and guidance, supporting their implementation of improvements and assessing and reporting on their performance. Ongoing clinical engagement is vital to our work, to ensure that our outputs are directly relevant to clinical staff and to support clinical staff in improving impact and implementation. NHSScotland staff participate in our peer review programmes; we make extensive use of part-time clinical advisors on our projects; and we run a range of networks and learning events for NHSScotland in support of our activities. NHS QIS collaborates with other Special Health Boards on a range of projects and activities (e.g. with NES on the development of a comprehensive nutritional care programme, with NSS (ISD) on clinical indicators and with both NES and NHS Health on practice development projects). The non-executive Board of NHS QIS includes a combination of lay and NHS membership to ensure a balanced view of our activities. 43

44 Public Sector We are active participants in multi-agency collaboration, building our relationships with existing partners and seeking out opportunities to work with other groups that contribute to quality improvement. During , with the Social Work Inspection Agency (SWIA) and the Care Commission, we piloted multi agency review of services for older people in Tayside and Forth Valley, spanning NHS Boards and local authorities. During , jointly with SWIA and the Care Commission, we reviewed general health services for people with learning disabilities, in every NHS Board. One of the aims of the creation of the two new scrutiny bodies, Healthcare Improvement Scotland and Social Care and Social Work Improvement Scotland, is to deliver a public sector that is proportionate, responsive and efficient in its approach. Joint working between the new bodies is seen as key to this. Voluntary Organisations We have broadened our Patient Focus and Public Involvement activity by working with voluntary organisations on a number of projects. Examples include: setting up advocacy groups for the development of standards for sexual health services, for neurology and for CHD; and involving representatives in the development of integrated care pathways for mental health. We have also commissioned Asthma UK and Diabetes UK to look at patient experience alongside our reviews of Board performance against clinical standards for asthma and diabetes. UK and international links A core objective of NHS QIS is to contribute to research and learning from experience on quality improvement, in Scotland, the UK and internationally, for example: NHS QIS is an active participant in the five-nations group of the bodies responsible for regulation and quality improvement in the British Isles and contributes to UK-wide quality improvement initiatives. NHS QIS regularly hosts visits from other countries interested in learning from the Scottish experience and in sharing approaches to quality improvement. We also regularly contribute exhibitions, poster abstracts and presentations to UK and international conferences on quality improvement in healthcare. 5. WORKFORCE / BUDGET NHS QIS budget has increased from just under 15m in , which for the first time included allocation for the work of SIGN and the Scottish Medicines Consortium, to an anticipated 17.3m in During , there was expenditure on activities in relation to the proposed relocation / collocation of NHS QIS to Glasgow. Nearly 1.5m has been received as non-recurring funding for the 2-year contract with IHI to support the Scottish Patient Safety Programme. The Scottish Health Council receives ring fenced funding (including inflationary uplift) on an annual basis, within the NHS QIS budget. Between 2005/06 and 2007/08 the total average staff in NHS QIS has increased from 226 to 244, resulting in staff costs increasing from 7.4m to 8.9m. This takes into account the transfer of staff from SIGN and Scottish Health Council. 44

45 6. REPORTING ARRANGEMENTS Each year, NHS QIS produces a delivery plan for sign off by the Chief Executive of NHSScotland. This sets out how NHS QIS will be judged in terms of performance on delivery of key outputs and against applicable HEAT targets. The Delivery Plan also highlights our indirect support for NHS Boards in meeting HEAT targets through programmes of work relating to national priorities. NHS QIS is subject to an Annual Review by the Cabinet Secretary for Health and Wellbeing / Minister for Public Health. The guidance for the Delivery Plan and Annual Review follows that of territorial health boards. We do not believe that this gives a full opportunity to reflect the role we play in supporting NHSScotland in meeting HEAT and other targets and in the wider quality improvement agenda. 7. FUTURE DEVELOPMENTS AND OPPORTUNITIES INTERFACE WITH TERRITORIAL BOARDS We have established a Directorate of Implementation and Improvement Support to provide a greater focus on supporting Boards with implementation of our advice and guidance, in line with our cycle of improvement. The establishment of the Healthcare Environment Inspectorate will bring an increased focus on scrutiny as part of the improvement cycle. The Scottish Health Council is leading the development of the Participation Standard, which will inform and shape future patient focus and public involvement activities and improve their monitoring. Increased engagement with Managed Clinical Networks (MCNs) is providing an opportunity to engage more directly with clinicians and service managers at an early stage to ensure our work contributes to improved quality of healthcare. INTERFACE WITH SPECIAL HEALTH BOARDS There are further opportunities to build on current shared activities in support of national strategies, including: a more coherent approach through greater integration of work programmes (e.g. with NES on patient safety education) clarification of the lead organisations in joint activities more systematic work planning and monitoring (currently fairly ad-hoc) more shared events, to reduce duplication and ensure better use of resources. INTERFACE WITH GOVERNMENT There are a number of opportunities to build on our existing relationships with SGHD: implementation of SGHD s new quality strategy, to ensure consistency of priorities and avoidance of duplication for NHS Boards revision of SGHD guidance for objective setting and reporting to provide Special Health Boards with a greater opportunity to give a full picture of current and potential contributions to the work of NHS Boards closer engagement from the outset in the development of national strategies and action plans would support streamlining of activity and expectations of NHS Boards improved inter-government / inter-division communication may reduce duplication of briefing and information requests and improve understanding across sponsor divisions of the work of Special Health Boards. 45

46 8. OTHER OPPORTUNITIES TO ADD VALUE Our principal opportunity is in continuing to critically appraise our methodology to ensure that our processes and outputs are fit for purpose, evidence-based and value for money, for example, shorter processes for developing standards and SIGN guidelines, more proportionate, risk-based performance assessment models, moves towards examining trend data rather than snapshot reviews. This allows us to add value by being more responsive and less burdensome, and by developing methodologies that will support services to adopt a continuous quality improvement approach. Alongside the establishment of Healthcare Improvement Scotland, the recommendations of the Crerar action groups particularly on User Focus, Accountability and Governance, and Reducing the Burden of Scrutiny will have implications for the work of NHS QIS and are currently under consideration. NHS QIS has been involved from the outset in Better Together, Scotland s patient experience programme. Our input has been to emphasise the need for the programme to focus on improvement in patient experience. The outputs of the programme (through work with patients and carers, patient surveys and existing qualitative evidence) will be of considerable benefit to NHS QIS in complementing the data it gathers on the quality of clinical care. 46

47 NHS National Services Scotland (NSS) CURRENT POSITION Role and Functions of NSS Purpose. NSS purpose is to deliver effective national and specialist services which enable and support improvements in the health and well being of all the people of Scotland Vision. To be valued as a world class partner that enables and supports the transformation in the health and wellbeing of all the people of Scotland. Mission. As a vital part of the NHS in Scotland, NSS enables and supports the delivery of better health and better care, working in partnership. Through the NSS Strategy Map, at Appendix 1, it can be seen how NSS has adopted an output based approach to service delivery and can clearly demonstrate the relationship between our Strategic Objectives with the associated outcomes and measures to the National Strategic Objectives and Outcomes. NSS works in almost every area of health service activity. Our services are delivered through our operational support groups with clinical and corporate support. Health Support. This includes: - Health Facilities Scotland; - Health Protection Scotland; - Information Services Division; - National Services Division; and - Scottish National Blood Transfusion Service. Business support. This includes: - Central Legal Office; - Counter Fraud Services; - National Information Systems Group; - National Procurement; - Practitioner Services; and - Scottish Health Service Centre. Health Facilities Scotland - Operational advice on all facilities topics. HFS provides operational guidance to NHSScotland healthcare bodies on non-clinical topics such as estates engineering, energy, environment, procurement and safety issues. We aim to establish professional/technical standards and best practice procedures within NHSScotland, including the promotion of new initiatives in the field of healthcare facilities practice and management. Health Protection Scotland - Coordinating health protection. HPS plans and delivers effective and specialist national services which co-ordinate, strengthen and support activities aimed at protecting all the people of Scotland from infectious and environmental hazards. We monitor the hazards and exposures, and their impact, affecting the people of Scotland and undertake research and development into health protection priorities. We co-ordinate the national health protection activity to ensure there is an effective response to outbreaks and incidents by providing expert 47

48 advice on health protection and when required providing operational support to local health protection organisations. We support the development of good professional practice and a competent and confident workforce in health protection. We also commission the national reference laboratory services. Information Services Division - Health statistics and analysis. ISD provides health information, statistical services and advice which supports NHSScotland in establishing improvements in healthcare and facilitating planning and decision-making. We support NHSScotland, the Scottish Government, local authorities and others by developing national datasets, and information governance standards. We regularly publish national statistics and other health service data and directly supporting NHSScotland Health priorities through series of programmes of information development work. These focus on key health areas within NHSScotland such as Cancer Information, Coronary Heart Disease and Stroke, Mental Health and other long term conditions, Patient Safety and Clinical Governance, and Waiting Times. National Services Division - Screening and specialist health services. NSD is responsible for commissioning national specialist clinical services; performance managing national managed clinical networks; co-ordinating national screening programmes; and administering national financial risk share schemes for high costs drugs on behalf of NHSScotland. Scottish National Blood Transfusion Service - Blood transfusion services. SNBTS is the specialist provider of transfusion medicine in Scotland, supplying high quality blood, tissues, products and services. We work with communities, hospitals and professionals to ensure that donations are used wisely and effectively for the benefit of patients. We are also involved in innovative research into new products, technologies and services to improve the care for transfusion patients in NHSScotland. Central Legal Office - Specialist legal services. CLO provides NHSScotland with legal advice and assistance in every area of law relevant to the health service. The service is delivered through expert solicitors, organised in a team structure, covering litigation, employment, commercial contracts and property, with specialist groups covering mental health and practitioner services law. Seminars and training courses presented by the CLO solicitors, are also important aspects of the service we provide. Counter Fraud Services - Deterring, detecting and investigating fraud. Counter Fraud Services exist to protect NHSScotland from fraud, using a centrally based, professionally accredited team of specialists dedicated to counter fraud work. Working in partnership with other NHSS organisations and professional associations, we raise awareness of the detrimental impact of fraud on the health service and investigate it when it occurs. National Information Systems Group - Supports the delivery of IM&T. NISG supports the ehealth agenda through the effective delivery of Information Management and Technology products and specialist services that will enable clinical process and efficiency improvements across Scotland. 48

49 National Procurement - Acquiring, storing and delivering goods and services. NP is responsible for delivering an efficient procurement service to all NHS Boards and health organisations from sourcing through to the delivery of products. Our three main functions are Strategic Sourcing, eprocurement & Systems and Logistics. Strategic Sourcing focuses on negotiating national contracts for health service products and services; eprocurement & Systems are implementing a common eprocurement system for NHSScotland; and the Logistics function is responsible for the delivery of products to all hospital wards and health organisations across Scotland. Practitioner Services - Family health service payments and patient registration. PSD is responsible, on behalf of NHS Boards for payment and payment verification services covering NHS Primary Care dentists, doctors, opticians and pharmacists for the NHS treatment and services they provide to the people of Scotland. As a by product of payment services to GPs PSD also maintain the national database of NHSScotland patient registrations (CHI). PSD manage the transfer GP medical records (540k pa). process payments ( 2b pa) and prescriptions. On behalf of the Scottish Dental Practice Board PSD are responsible for monitoring standards of clinical care provided by NHS Dentists. Scottish Health Service Centre - Conference facilities and event organising. SHSC offers professional and administrative services, including event management and conference facilities. We also provide support services to NHSScotland national committees and host the Health Management Library and Information Service for Scotland. SELECTED EXAMPLES OF SUCCESS AND ADDED VALUE The following selected examples highlight where NSS has added value and delivered successful services on a national basis across Scotland. The list is not exhaustive but demonstrates not only the diversity of our services but also how providing these services nationally removes the burden form individual Health Boards. Improving Services Information Services (ISD) has developed SPARRA (Scottish Patients at Risk of Readmission or Admission), an information tool that can be used to assess a patient's risk of emergency inpatient admission. Details of patients who are identified as high risk by SPARRA are shared routinely with all health boards and Community Health Partnerships (CHPs). The information is used locally to identify and target patients with complex care needs who may benefit from additional case management or co-ordination. During 2008 ISD developed a similar tool to assess a patient's risk of psychiatric admission. ISD has developed Navigator, to provide direct web-based access to a range of information for healthcare staff in NHS boards and CHPs. It allows comparison of information at NHS board level and allows the user to drill down to review the more detailed information that underpins the indicator (at CHP, GP practice, hospital, specialty and consultant level). Navigator is being developed further, with additional functionality and features. 49

50 Improving Health National Services Division has successfully supported 10 NHS Boards to date in introducing Bowel Screening in addition to commissioning and managing some 90m of national services, ensuring they provide clinically effective care and equality of access to all the residents of Scotland. In 2007/08 NSD supported NHS Boards in implementing a new integrated call/recall and electronic transfer of results system for cervical screening (SCCRS). Due to the integration of this system across NHS Board boundaries, primary care, laboratories, community and family planning clinics, it needed to be introduced over a single weekend to over 12,000 users. Health Protection Scotland has successfully developed and managed the HPV vaccination programme for girls aged and also the catch up programme for girls up to 18 years old. In addition HPS is currently leading the Health Protection response to the Swine Flu outbreak providing national guidance to SGHD and Health Boards and providing the link to the Health Protection Agency. Scottish National Blood Transfusion Service has ensured that blood and tissues are collected tested and processed according to stringent regulation enabling a consistent approach to the safety and availability of blood components. SNBTS has enabled the development and deployment of blood safety measures (such as vcjd precautions) cost effectively, quickly and at scale meeting the national demand for blood and tissue products, again negating the need for individual Boards to develop costly human and physical infrastructure, clearly demonstrating efficiencies in providing the service nationally. In addition SNBTS provides a range of specialist clinical services at national and regional level such as a blood group reference services and tissue typing (in support of transplantation) that would not be viable at health board level. The Oxygen Concentrator service supports 3,000 people across Scotland. Among a number of initiatives within the substance misuse area, an Alcohol Brief Interventions minimum data set has been implemented to measure the introduction of a preventative intervention for patients being seen for problems and conditions relating to excess alcohol consumption, The data produced will support, at National level, the HEAT target for Boards to deliver 149,449 alcohol brief interventions cumulatively over the period 2008/ /11. A secondary more detailed dataset is also in place to help obtain more specific demographic and health related information about the patients being seen, for use at a local level. Achieving Economies of Scale National Procurement continues as a Centre of Expertise and plays an important role in leading procurement reform across NHSS. Since its launch in 2005 NP has developed to supply of over 9000 products to NHS Scotland, with over 700m of goods and services on national contract. In the past year alone NP has delivered over 9m of savings through logistics and 24m through strategic sourcing. Since 2000, the Counter Fraud Service has saved the NHS over 15m. Practitioner Services Division has paid circa 2b to Boards Primary Care Practitioners, a role undertaken nationally that removes the duplication of each Health Board having to maintain complex IT systems and processes for assessing, verifying and making the payments. The SNBTS services described above could also be included under this heading of achieving economies of scale. 50

51 Minimising Unnecessary Duplication of Investment and Effort The NHSS Shared Support Services Programme is supporting Health Boards to develop shared working for Finance & Payroll. Four Consortia of Health Boards have been formed for this purpose and, through the implementation of a common finance system and improved processes, 7.1m of Efficient Government savings have been made to date. All of the Services listed under Improving Health above could equally be described as minimising unnecessary duplication, as it could be argued that if NSS did not provide these services then each Health Board would have to provide them for their own use. Health Facilities Scotland (HFS) acts on behalf of NHSS in managing the Property Framework, which is a procurement initiative that adopts a collaborative approach to the delivery of capital projects and harnesses the advantages of long term relationships and an integrated supply chain. It addresses the failures of traditional procurement which on many occasions resulted in cost overruns, delayed handover and a dissatisfied end user. To date twenty six projects had been registered with the Framework at an overall value of 968m. Nineteen appointments have been made to develop the projects to Outline Business Case or Full Business Case. KEY CHANGES AND IMPROVEMENTS Customer Focus. NSS has developed a customer focussed service delivery strategy in support of its Vision statement. There are two key elements to this initiative; conducting annual customer effectiveness surveys and deploying Customer Relationship Managers in Boards. Surveys are conducted annually by NSS and analysed internally by ISD. The issues identified from these surveys are then addressed in the business plans and by direct engagement. NSS is currently piloting a scheme to recruit and deploy Customer Relationship Mangers in to each Health Board. The purpose of these posts will be to ensure each Board has access to and can make best use of the services NSS offers. Process Development and Improvement. There has been a focus on process development and improvement to support efficiencies and to join up the organisation by developing clear processes for adoption throughout NSS. This had led to clear process being developed within the HR function and elsewhere in NSS Realignment. Several areas within NSS have been realigned to ensure they are organised and resourced to provide efficient and cost effective service that will benefit both NSS and external customers. Values. NSS is introducing and embedding a single set of values and associated behaviours across the organisation. This is in support of our objective to support staff and also to assist in the joining up of the organisation. It will also serve to demonstrate what behaviours our customers should expect to experience and ultimately improve peoples perception of NSS. 51

52 INTERFACES Round Table Group. The Director of Finance and Director of Planning have both been invited to join the SGHD Round Table Group, which comprises sponsors for NSS and the Divisions. Although only present for alternate meetings this gives an opportunity to discuss emerging issues face to face with sponsors and ensure total visibility of delivery and financial issues. The meetings are also ideal for discussing LDP target formulation, performance related issues and preparations for the Annual Review. In addition to the formal Round Table Group meeting both the Director of Finance and Director of Planning have monthly one to one meetings with lead sponsors in SGHD. Regional Planning Groups. In accordance with SGHD Guidance on Regional Planning for Health Services (HDL(2002)10) the Director of NSD is a member of each of the Regional Planning Groups to ensure integration of regional and national planning. Through this link, there is an opportunity for close working between NSS and Regional Planning Groups. The Chief Executive also intends to attend RPG meetings in summer 2009 to ensure visibility of NSS services. Wider Engagement. NSS is represented at a range of monthly NHSS meetings including the Chief Executives Group, Directors of Planning, Finance Medical, Nursing and HR monthly meetings. In addition individuals at CEO and Director level are members of wider groups such as the Procurement Reform Board, ehealth Steering Group, Pandemic Influenza Steering Group, Management Steering Group, and the UK Blood Transfusion Group, the Scottish Transfusion Advisory Committee UK Blood Transfusion Forum, the European Blood Alliance the Scottish Bio -Industry Association, the Scottish Centre for Regenerative Medicine and Roslin Cells. FORMAL PROCESSES FOR OBJECTIVE SETTING AND REPORTING The annual objective setting process starts in September with the Board reviewing and agreeing the Purpose, Mission and Vision Statements, and the Strategic Objectives. During this process alignment with the Scottish Government s Strategic Outcomes is confirmed. This planning process is then continued through the autumn and winter, incorporating targets for inclusion in the Local Delivery Plan. In January and February each Division and Department presents its service delivery objectives for the forthcoming year at individual Resource Allocation meetings. It as at these meeting that the CEO formally endorses the Business Plans using the strategic Outcome Matrix and agrees the associated financial and workforce plans. At the Board meeting in March the Board debates the Local Delivery Plan and the Strategic Outcomes Matrix and agrees the budget for the forthcoming year. Performance against the Local Delivery Plan and the Strategic Outcomes Matrix is reviewed quarterly by the Director of Strategic Planning and Performance Management. In addition the CEO conducts mid and end of year performance reviews with each Director. Progress against the LDP is reported to the Board and SGHD at the mid year and end of year. Performance is also discussed between NSS Directors and SGHD sponsors at the quarterly Round Table Meetings described above. 52

53 BUDGET AND WORKFORCE The Budget and workforce changes over the past 3-5 years are summarised below. Budget. Since 04/05 the Revenue Resource Limit (RRL) for NSS increased as follows 2005/06 Baseline Additional Allocations Total RRL 2006/07 Baseline Additional Allocations Total RRL 2007/08 Baseline Additional Allocations Total RRL 2008/09 Baseline Additional Allocations Total RRL 194,500k 68,800k 263,300k 217,200k 74,800k 292,000k 238,100k 132,100k 370,200k 247,200k 152,100k 399,300k The significant rise in 07/08 was partly a result of the way NISG was accounted for prior to Workforce. The NSS workforce overall figures since 2007 are WTE WTE WTE The key reasons for the changes are due to o 20 Health Facilities Scotland Staff transferring to NSS o National Procurement staff levels increasing by 90 over the period o The Transfer of 57 staff to Alba Bioscience o Loss of 112 staff on the closure of the Protein Fractionation Centre 53

54 FUTURE DEVELOPMENTS AND OPPORTUNITIES INTERFACE WITH TERRITORIAL BOARDS The Customer Relationship Management initiative was covered above, but has already proved to be an successful engagement process, that provides benefits to the Territorial Boards. During the first pilot with NHS Shetland, by working together, NSS and NHS Shetland were able to identify some 100k of savings by increased uptake of NSS services. It is expected this initiative will be rolled out to all Boards in 09/10. INTERFACE WITH SPECIAL HEALTH BOARDS As part of the review process, closer working between Special Health Boards should be considered to remove duplication identify synergies and maximise efficiencies though closer working. Such areas could include shared support functions, transport management and procurement. INTERFACE WITH GOVERNMENT NSS has the potential to increase support for the Efficient Government agenda beyond that already been achieved through National Procurement. This will require closer working with other Government Directorates without detriment to the support provided to SGHD and the wider NHS in Scotland. OTHER OPPORTUNITIES TO ADD VALUE By continuing with a focus on NSS customers it is expected that NSS will be able to identify efficiencies and savings through greater use of NSS services, develop our services to better meet the customer requirement, and expand the delivery portfolio within existing resources. 54

55 NSS Strategy Map Appendix 1 55

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